We all know we need to do much more for Indigenous health. What we don’t always know is how best to go about doing more to reduce and ideally eliminate Indigenous health inequities. One of the common pitfalls that health professionals and healthcare organizations make when it comes to Indigenous health is to believe that the answer lies in learning more about Indigenous culture, customs and practices. We argue that this positioning is flawed and potentially harmful. A focus away from cultural competency and onto cultural safety is necessary if we are to realize Indigenous health potential.
So, what is the difference between cultural ‘competency’ and ‘safety’? Our recent literature review examined 59 international articles on the definitions of cultural competency and cultural safety over time. Early definitions of cultural competency focused on the acquisition of knowledge about the ‘exotic’ cultural other. Contextualized to transcultural interactions between the assumed ‘White’ physician and culturally different patient, early proponents of cultural competency encouraged health professionals to maintain their expert status as they appropriated knowledge, skills and attitudes about Indigenous patients and their culture.
The assumptions inherent in a cultural competency approach is that there is a level of ‘competency’ that can be acquired (like a tick box), that Indigenous peoples can be homogenized into a collective ‘they’ and that a lack of knowledge about Indigenous people and their culture is the major cause of Indigenous health inequities. Cultural safety on the other hand, requires health professionals and their organizations to look at their own culture and to examine their own customs and practices that may be harmful to Indigenous peoples.
This positioning does not frame a lack of knowledge about Indigenous culture as the problem and is explicit in the need for health professionals and their organizations to regularly examine their own ‘culture’ in terms of biases, attitudes, assumptions, stereotypes, prejudices, structures and characteristics that may affect the quality of care provided to Indigenous peoples. This term, developed by Dr Irihapeti Ramsden and Māori nurses in Aotearoa New Zealand in the late 1980’s, explicitly acknowledges the power differential inherent in clinical encounters. Cultural safety requires a shift in power away from the health professional. It is the Indigenous patient and their community who should decide on whether an interaction is culturally safe (or not).
The literature base is now clear that cultural competency, whilst being necessary to some degree, is not sufficient to eliminate health inequities for Indigenous peoples. A movement towards ‘criticial consciousness’ is required. Health professionals 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.
The literature is also clear, that cultural safety is required not just from individual practitioners, but also from healthcare organizations operating at a structural level. 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).
Following our review of the international literature, we have proposed a definition for cultural safety that we believe to be more fit for purpose in achieving health equity and we clarify the essential principles and practical steps to operationalise this approach in healthcare organizations and workforce development.
We understand that committing to cultural safety may be challenging and confronting. So be it. We must never accept Indigenous health inequities as being normal or acceptable and this will require significant shifts in our approach to achieving health equity.