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

Internationally, Indigenous and minoritorised ethnic groups experience inequities in their exposure to the determinants of health, access to and through healthcare and receipt of high quality healthcare [1]. The role of health providers and health systems in creating and maintaining these inequities is increasingly under investigation [2]. As such, the cultural competency and cultural safety of healthcare providers are now key areas of concern and issues around how to define these terms have become paramount, particularly within a Aotearoa New Zealand (NZ) context [3]. This article explores international literature to clarify the concepts of cultural competency and cultural safety in order to better inform both local and international contexts.

In NZ, Māori experience significant inequities in health compared to the non-Indigenous population. In 2010–2012, Māori life expectancy at birth was 7.3 years less than non-Māori [4] and Māori have on average the poorest health status of any ethnic group in NZ [5, 6]. Although Māori experience a high level of health care need, Māori receive less access to, and poorer care throughout, the full spectrum of health care services from preventative to tertiary care [7, 8]. This is reflected in lower levels of investigations, interventions, and medicines prescriptions when adjusted for need [8, 9]. Māori are consistently and significantly less likely to: get understandable answers to important questions asked of health professionals; have health conditions explained in understandable terms; or feel listened to by doctors or nurses [10]. The disturbing health and social context for Māori and significant inequities across multiple health and social indicators described above provide the ‘needs-based’ rationale for addressing Māori health inequities [8]. There are equally important ‘rights-based’ imperatives for addressing Indigenous health and health equity [11], that are reinforced by the United Nations Declaration on the Rights of Indigenous Peoples [12] and Te Tiriti o Waitangi (Treaty of Waitangi) in NZ.

There are multiple and complex factors that drive Indigenous and ethnic health inequities including a violent colonial history that resulted in decimation of the Māori population and the appropriation of Māori wealth and power, which in turn has led to Māori now having differential exposure to the determinants of health [13] [14] and inequities in access to health services and the quality of the care received. Framing ethnic health inequities as being predominantly driven by genetic, cultural or biological differences provides a limited platform for in-depth understanding [15, 16]. In addition, whilst socio-economic deprivation is associated with poorer health outcomes, inequities remain even after adjusting for socio-economic deprivation or position [17]. Health professionals and health care organisations are important contributors to racial and ethnic inequities in health care [2, 13]. The therapeutic relationship between a health provider and a patient is especially vulnerable to the influence of intentional or unintentional bias [18, 19] leading to the “paradox of well-intentioned physicians providing inequitable care [20]. Equitable care is further compromised by poor communication, a lack of partnership via participatory or shared decision-making, a lack of respect, familiarity or affiliation and an overall lack of trust [18]. Healthcare organisations can influence the structure of the healthcare environment to be less likely to facilitate implicit (and explicit) bias for health providers. Importantly, it is not lack of awareness about ‘the culture of other groups’ that is driving health care inequities - inequities are primarily due to unequal power relationships, unfair distribution of the social determinants of health, marginalisation, biases, unexamined privilege, and institutional racism [13]. Health professional education and health institutions therefore need to address these factors through health professional education and training, organisational policies and practices, as well as broader systemic and structural reform.

Eliminating Indigenous and ethnic health inequities requires addressing the social determinants of health inequities including institutional racism, in addition to ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care delivery. Some jurisdictions have included cultural competency in health professional licensing legislation [21], health professional accreditation standards, and pre-service and in-service training programmes [22‐25]. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them. This article reviews how concepts of cultural competency and cultural safety (and related terms such as cultural sensitivity, cultural humility etc) have been interpreted. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for why broader conceptualisation of these terms is needed to achieve health equity. A move to cultural safety is recommended, with a rationale for why this approach is necessary. We propose a definition for cultural safety and clarify the essential principles of this approach in healthcare organisations and workforce development.

This review was originally conducted to inform the Medical Council of New Zealand, in reviewing and updating its approach to cultural competency requirements for medical practitioners in New Zealand Aotearoa. The review and its recommendations are based on the following methods:

The authors reflect expertise that includes Te ORA membership, membership of the Australasian Leaders in Indigenous Medical Education (LIME) (a network to ensure the quality and effectiveness of teaching and learning of Indigenous health in medical education), medical educationalist expertise and Indigenous medical practitioner and public health medicine expertise across Australia and NZ. This experience has been at the forefront of the development of cultural competency and cultural safety approaches within NZ. The analysis has been informed by the framework of van Ryn and colleagues [27] which frames health provider behaviour within a broader context of societal racism. They note the importance of shifting “the framing of the problem, from ‘the impact of patient race’ to the more accurate ‘impact of racism’….on clinician cognitions, behaviour, and clinical decision making” [27].

This review and analysis has been conducted from an Indigenous research positioning that draws from Kaupapa Māori theoretical and research approaches. Therefore, the positioning used to undertake this work aligns to effective Kaupapa Māori research practice that has been described by Curtis (2016) as: transformative; beneficial to Māori; under Māori control; informed by Māori knowledge; aligned with a structural determinants approach to critique issues of power, privilege and racism and promote social justice; non-victim-blaming and rejecting of cultural-deficit theories; emancipatory and supportive of decolonisation; accepting of diverse Māori realities and rejecting of cultural essentialism; an exemplar of excellence; and free to dream [28].

The literature review searched international journal databases and the grey literature. No year limits were applied to the original searching. Databases searched included: Medline, Psychinfo, Cochrane SR, ERIC, CINAHL, Scopus, Proquest, Google Scholar, EbscoHost and grey literature. Search terms included MeSH terms of cultural competence (key words: cultural safety, cultural awareness, cultural competence, cultural diversity, cultural understanding, knowledge, expertise, skill, responsiveness, respect, transcultural, multicultural, cross-cultur*); education (key words: Educat*, Traini*, Program*, Curricul*, Profession*, Course*, Intervention, Session, Workshop, Skill*, Instruc*, program evaluation); Health Provider (key words: provider, practitioner, health professional, physician, doctor, clinician, primary health care, health personnel, health provider, nurse); Health Services Indigenous (key words: health services Indigenous, ethnic* Minorit*, Indigenous people*, native people). A total of 51 articles were identified via the search above and an additional 8 articles were identified via the authors’ opportunistic searching. A total of 59 articles published between 1989 and 2018 were used to inform this review. Articles reviewed were sourced from the USA, Canada, Australia, NZ, Taiwan and Sweden (Additional file 1 Table S1).

In addition to clarifying concepts of cultural competence and cultural safety, a clearer understanding is required of how best to train and monitor for cultural safety within health workforce contexts. An assessment of the availability and effectiveness of tools and strategies to enhance cultural safety is beyond the scope of this review, but is the subject of a subsequent review in process.

Cultural competency is a broad concept that has various definitions drawing from multiple frameworks. Overall, this concept has varying interpretations within and between countries (see Table 1 for specific examples). Introduced in the 1980s, cultural competency has been described as a recognised approach to improving the provision of healthcare to ethnic minority groups with the aim of reducing ethnic health disparities [31].

One of the earliest [49] and most commonly cited definitions of cultural competency is sourced from a 1989 report authored by Cross and colleagues in the United States of America [29] (p.13):

Cultural competence is a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations.

Cross et al. [29] contextualized cultural competency as part of a continuum ranging from the most negative end of cultural destructiveness (e.g. attitudes, policies, and practices that are destructive to cultures and consequently to the individuals within the culture such as cultural genocide) to the most positive end of cultural proficiency (e.g. agencies that hold culture in high esteem, who seek to add to the knowledge base of culturally competent practice by conducting research and developing new therapeutic approaches based on culture). Other points along this continuum include: cultural incapacity, cultural blindness and cultural pre-competence (Table 1).

By the time that cultural competency became to be better understood in the late 1990s, there had been substantial growth in the number of definitions, conceptual frameworks and related terms [31, 50‐52]. Table 1 provides a summary of the multiple, interchangeable, terms such as: cultural awareness; cultural sensitivity; cultural humility; cultural security; cultural respect; cultural adaptation; and transcultural competence or effectiveness. Unfortunately, this rapid growth in terminology and theoretical positioning(s), further confused by variations in policy uptake across the health sector, reduced the potential for a common, shared understanding of what cultural competency represents and therefore what interventions are required. Table 2 outlines the various definitions of cultural competency from the literature.

Cultural competence was often defined within an individually-focused framework, for example, as:

the ability of individuals to establish effective interpersonal and working relationships that supersede cultural differences by recognizing the importance of social and cultural influences on patients, considering how these factors interact, and devising interventions that take these issues into account [53] (p.2).

Some positionings for cultural competency have been critiqued for promoting the notion that health-care professionals should strive to (or even can) master a certain level of functioning, knowledge and understanding of Indigenous culture [61]. Cultural competency is limited when it focuses on acquiring knowledge, skills and attitudes as this infers that it is a ‘static’ level of achievement [58]:

“cultural competency” is frequently approached in ways which limit its goals to knowledge of characteristics, cultural beliefs, and practices of different nonmajority groups, and skills and attitudes of empathy and compassion in interviewing and communicating with nonmajority groups. Achieving cultural competence is thus often viewed as a static outcome: One is “competent” in interacting with patients from diverse backgrounds much in the same way as one is competent in performing a physical exam or reading an EKG. 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 (p.783).

By the early 2000s, governmental policies and cultural competency experts [50, 54] had begun to articulate cultural competency in terms of both individual and organizational interventions, and describe it with a broader, systems-level focus, e.g.:

the ability of systems to provide care to patients with diverse values, beliefs and behaviours, including tailoring delivery to meet patients’ social, cultural, and linguistic needs [54] (p. v).

Moreover, some commentators began to articulate the importance of critical reflection to cultural competency. For example, Garneau and Pepin [55] align themselves more closely to the notion of cultural safety when they describe cultural competency as:

a complex know-act grounded in critical reflection and action, which the health care professional draws upon to provide culturally safe, congruent, and effective care in partnership with individuals, families, and communities living health experiences, and which takes into account the social and political dimensions of care [55] (p. 12).

A key difference between the concepts of cultural competency and cultural safety is the notion of ‘power’. There is a large body of work, developed over many years, describing the nuances of the two terms [34, 36, 38, 43, 46, 49, 59, 62‐69]. Similar to cultural competency, this concept has varying interpretations within and between countries. Table 3 summarises the definitions and use of cultural safety from the literature. Cultural safety foregrounds power differentials within society, the requirement for health professionals to reflect on interpersonal power differences (their own and that of the patient), and how the transfer of power within multiple contexts can facilitate appropriate care for Indigenous people and arguably for all patients [32].

The term cultural safety first was first proposed by Dr. Irihapeti Ramsden and Māori nurses in the 1990s [74], and in 1992 the Nursing Council of New Zealand made cultural safety a requirement for nursing and midwifery education [32]. Cultural safety was described as providing:

a focus for the delivery of quality care through changes in thinking about power relationships and patients’ rights [32]. (p.493).

Cultural safety is about acknowledging the barriers to clinical effectiveness arising from the inherent power imbalance between provider and patient [65]. This concept rejects the notion that health providers should focus on learning cultural customs of different ethnic groups. Instead, cultural safety seeks to achieve better care through being aware of difference, decolonising, considering power relationships, implementing reflective practice, and by allowing the patient to determine whether a clinical encounter is safe [32, 65].

Cultural safety requires health practitioners to examine themselves and the potential impact of their own culture on clinical interactions. This requires health providers to question their own biases, attitudes, assumptions, stereotypes and prejudices that may be contributing to a lower quality of healthcare for some patients. In contrast to cultural competency, the focus of cultural safety moves to the culture of the clinician or the clinical environment rather than the culture of the ‘exotic other’ patient.

There is debate over whether cultural safety reflects an end point along a continuum of cultural competency development, or, whether cultural safety requires a paradigm shift associated with a transformational jump in cultural awareness. Dr. Irihapeti Ramsden [75] originally described the process towards achieving cultural safety in nursing and midwifery practice as a step-wise progression from cultural awareness through to cultural sensitivity and on to cultural safety. However, Ramsden was clear that the terms cultural awareness and cultural sensitivity were separate concepts and that they were not interchangeable with cultural safety. Despite some authors interpreting Ramsden’s original description of cultural safety as involving three steps along a continuum [35] other authors view a move to cultural safety as more of a ‘paradigm shift’ [63]:

where 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]. (p.10).

Regardless of whether cultural safety represents movement along a continuum or a paradigm shift, commentators are clear that the concept of cultural safety aligns with critical theory, where health providers are invited to “examine sources of repression, social domination, and structural variables such as class and power” [71] (p.144) and “social justice, equity and respect” [76] (p.1). This requires a movement to critical consciousness, involving critical self-reflection: “a stepping back to understand one’s own assumptions, biases, and values, and a shifting of one’s gaze from self to others and conditions of injustice in the world.” [58] (p.783).

Unfortunately, regulatory and educational health organisations have tended to frame their understanding of cultural competency towards individualised rather than organisational/systemic processes, and on the acquisition of cultural-knowledge rather than reflective self-assessment of power, priviledge and biases. There are a number of reasons why this approach can be harmful and undermine progress on reducing health inequities.

Individual-level focused positionings for cultural competency perpetuate a process of “othering”, that identifies those that are thought to be different from oneself or the dominant culture. The consequences for persons who experience othering include alienation, marginalization, decreased opportunities, internalized oppression, and exclusion [77]. To foster safe and effective health care interactions, those in power must actively seek to unmask othering practices [78].

“Other-focused” approaches to cultural competency promote oversimplified understandings of other cultures based on cultural stereotypes, including a tendency to homogenise Indigenous people into a collective ‘they’ [79]. This type of cultural essentialism not only leads to health care providers making erroneous assumptions about individual patients which may undermine the provision of good quality care [31, 53, 58, 63, 64], but also reinforces a racialised, binary discourse, used to repeatedly dislocate and destabilise Indigenous identity formations [80]. By ignoring power, narrow approaches to cultural competency perpetuate deficit discourses that place responsibility for problems with the affected individuals or communities [81], overlooking the role of the health professional, the health care system and broader socio-economic structures. Inequities in access to the social determinants of health have their foundations in colonial histories and subsequent imbalances in power that have consistently benefited some over others. Health equity simply cannot be achieved without acknowledging and addressing differential power, in the healthcare interaction, and in the broader health system and social structures (including in decision making and resource allocation) [82].

An approach to cultural competency that focuses on acquiring knowledge, skills and attitudes is problematic because it suggests that competency can be fully achieved through this static process [58]. Cultural competency does not have an endpoint, and a “tick-box” approach may well lull practitioners into a falsely confident space. These dangers underscore the importance of framing cultural safety as an ongoing and reflective process, focused on ‘critical consciousness’. There will still be a need for health professionals to have a degree of knowledge and understanding of other cultures, but this should not be confused with or presented as efforts to address cultural safety. Indeed, as discussed above, this information alone can be dangerous without deep self-reflection about how power and privilege have been redistributed during those processes and the implications for our systems and practice.

By neglecting the organisational/systemic drivers of health care inequities, individual-level focused positionings for cultural competency are fundementally limited in their ability to impact on health inequities. Healthcare organisations influence health provider bias through the structure of the healthcare environment, including factors such as their commitment to workforce training, accountability for equity, workplace stressors, and diversity in workforce and governance [27]. Working towards cultural safety should not be viewed as an intervention purely at the level of the health professional – although a critically conscious and empathetic health professional is certainly important. The evidence clearly emphasises the important role that healthcare organisations (and society at large) can have in the creation of culturally safe environments [31, 32, 46, 60, 69]. Cultural safety initiatives therefore should target both individual health professionals and health professional organisations to intervene positively towards achieving health equity.

Perhaps not surprisingly, the concept of cultural safety is often more confronting and challenging for health institutions, professionals, and students than that of cultural competency. Regardless, it has become increasingly clear that health practitioners, healthcare organisations and health systems all need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the ‘taken for granted’ power structures and be prepared to challenge their own culture, biases, privilege and power rather than attempt to become ‘competent’ in the cultures of others.

It is clear from reviewing the current evidence associated with cultural competency and cultural safety that a shift in approach is required. We recommend an approach to cultural safety that encompasses the following core principles:

We recommend that the following definition for cultural safety is adopted by healthcare organisations:

“Cultural safety requires healthcare professionals and their associated healthcare organisations to examine themselves and the potential impact of their own culture on clinical interactions and healthcare service delivery. This requires individual healthcare professionals and healthcare organisations to acknowledge and address their own biases, attitudes, assumptions, stereotypes, prejudices, structures and characteristics that may affect the quality of care provided. In doing so, cultural safety encompasses a critical consciousness where healthcare professionals and healthcare organisations engage in ongoing self-reflection and self-awareness and hold themselves accountable for providing culturally safe care, as defined by the patient and their communities, and as measured through progress towards acheiveing health equity. Cultural safety requires healthcare professionals and their associated healthcare organisations to influence healthcare to reduce bias and achieve equity within the workforce and working environment”.

In operationalising this approach to cultural safety, organisations (health professional training bodies, healthcare organisations etc) should begin with a self-review of the extent to which they meet expectations of cultural safety at a systemic and organizational level and identify an action plan for development. The following steps should also be considered by healthcare organisations and regulators to take a more comprehensive approach to cultural safety:

Cultural competency, cultural safety and related terms have been variably defined and applied. Unfortunately, regulatory and educational health organisations have tended to frame their understanding of cultural competency towards individualised rather than organisational/systemic processes, and on the acquisition of cultural-knowledge rather than reflective self-assessment of power, priviledge and biases. This positioning has limited the impact on improving health inequities. A shift is required to an approach based on a transformative concept of cultural safety, which involves a critique of power imbalances and critical self-reflection.

Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the ‘taken for granted’ power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming ‘competent’ in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity.

We propose principles and a definition for cultural safety that addresses the key factors identified as being responsible for ethnic inequities in health care, and which we therefore believe is fit for purpose in Aotearoa New Zealand and internationally. We hope this will be a useful starting point for users to further reflect on the work required for themselves, and their organisations, to contribute to the creation of culturally safe environments and therefore to the elimination of Indigenous and ethnic health inequities. More work is needed on how best to train and monitor for cultural safety within health workforce contexts.