Background material

Origin and policy context

The concept of cultural safety has been around for some time, with the notion originally defined and applied in the cultural context of New Zealand. It originated there in response to the harmful effects of colonisation and the ongoing legacy of colonisation on the health and healthcare of Maori people—in particular in mainstream health care services.

A commonly accepted definition of cultural safety from the Nursing Council of New Zealand (2002:7) is the ‘effective nursing or midwifery practice of a person or family from another culture, and is determined by that person or family… Unsafe cultural practice comprises any action which diminishes, demeans or disempowers the cultural identity and wellbeing of an individual.’

A distinctive feature of this definition of cultural safety is its emphasis on the provision of culturally safe health care services as defined by the end users of those services, notably, the Maori people of Aotearoa New Zealand, not by the (non-Maori) providers of care.

The National Collaboration Centre for Indigenous Health in Canada (2013) notes that culturally safe health care systems and environments are established by a continuum of building blocks:

Cultural awareness ⟹

Cultural sensitivity ⟹

Cultural competency ⟹

Cultural safety

The centre states that cultural safety ‘…requires practitioners to be aware of their own cultural values, beliefs, attitudes and outlooks that consciously or unconsciously affect their behaviours. Certain behaviours can intentionally or unintentionally cause clients to feel accepted and safe, or rejected and unsafe. Additionally cultural safety is a systemic outcome that requires organizations to review and reflect on their own policies, procedures, and practices in order to remove barriers to appropriate care.’

In Australia, there has been increasing recognition that improving cultural safety for Aboriginal and Torres Strait Islander health care users can improve access to, and the quality of health care. This means a health system where Indigenous cultural values, strengths and differences are respected; and racism and inequality is addressed.

There are difficulties in both defining and measuring generalised concepts such as cultural respect and cultural safety. They include lack of conceptual clarity and agreement on terms, the qualitative nature of the concepts, and the diversity of Indigenous Australians and their perceptions. The Australian literature uses various definitions of cultural safety, and related concepts such as cultural respect and cultural competency, and what these mean in relation to the provision of health care.

For the purpose of developing a monitoring framework cultural safety is defined with reference to the experience of the Indigenous health care consumer, of the care they are given, their ability to access services and to raise concerns. Some of the essential features of cultural safety include an understanding of one’s culture; an acknowledgment of difference, and a requirement that caregivers are actively mindful and respectful of this difference. The presence or absence of cultural safety is determined by the experience of the recipient of care and is not defined by the caregiver (AHMAC 2016).

Two important aspects of culturally safe health care across the literature are, how it is provided and how it is experienced, and these form the basis for the monitoring framework (see AHMAC 2016; CATSINAM 2014; AIDA 2014; DHHS 2016; NACCHO 2011; Department of Health 2015).

How health care is provided

  • behaviour, attitude and culture of providers: respects and understands Indigenous culture and people
  • defined with reference to the provision of care, including governance structures, policies and practices

How health care is experienced  by Indigenous people

  • feeling safe, connected to culture and cultural identity is respected
  • can only be defined by those who receive health care

The importance of cultural respect and cultural safety is outlined in Australian government documents such as the Cultural Respect Framework 2016–26 for Aboriginal and Torres Strait Islander Health, and the National Aboriginal and Torres Strait Islander Health Plan 2013–23. The Australian Commission on Safety and Quality in Healthcare (ACSQHC) also included six Aboriginal and Torres Strait Islander specific actions in the National Safety and Quality Health Service Standards to improve care for Aboriginal and Torres Strait Islander people in mainstream health services.

Development of a monitoring framework

The Cultural safety in health care: monitoring framework aims to measure progress in achieving cultural safety in the Australian health system by bringing together data related to cultural safety. Specifically, to measure progress in achieving cultural safety in the health system under the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–23. The framework can also assist in measuring progress in achieving cultural safety under the Cultural Respect Framework which commits the Commonwealth Government, and states and territories, to embed cultural respect principles into their health systems; from developing policy and legislation, to how organisations are run, through to the planning and delivery of services.

In consultation with key stakeholders, including the National Aboriginal and Torres Strait Islander Health Standing Committee and the Implementation Plan Advisory Group, this framework was developed through a review of relevant policy documents, academic literature, and potential national and state level data sources.

The framework has 3 reporting modules which each include a range of measures focussing on culturally respectful health care services, patient experience of health care among Indigenous Australians, and access to health care as an indirect measure of cultural safety.

Reporting against the framework

This Cultural safety in health care: monitoring framework brings together available national and state and territory level data to provide a picture of cultural safety in the health system. The scope of national and state and territory level data currently available are limited and further development is required to enable more comprehensive reporting. See data gaps in Culturally respectful health care services, Patient experience of health care, and Access to health care services.

Monitoring cultural safety and cultural respect in the health system, and the impact it has on access to appropriate health care, are limited by a lack of national and state level data. This is particularly the case in relation to reporting on the policies and practices of mainstream health services, such as primary health care services.

There are also limited data on the experiences of Indigenous health care users. Most jurisdictions undertake patient experience surveys in public hospitals, but there is little data on Indigenous Australians for reporting. A high proportion of Indigenous Australians use mainstream health services, so further data developments in this area are required to allow for more comprehensive reporting across the health sector.

As data developments occur and more comprehensive data become available, the cultural safety monitoring framework will be expanded and updated.

References

AHMAC (Australian Health Ministers’ Advisory Council) 2016. Cultural Respect Framework 2016–26 for Aboriginal and Torres Strait Islander Health: a national approach to building a culturally respectful health system. Canberra: AHMAC.

AHMAC 2017. Aboriginal and Torres Strait Islander Health Performance Framework 2017 Report. Canberra: AHMAC.

AIDA (Australian Indigenous Doctors’ Association) 2013. Position Paper Cultural Safety for Aboriginal and Torres Strait Islander Doctors, Medical Students and Patients, Canberra: AIDA.

CATSINaM (Congress of Aboriginal and Torres Strait Islander Nurses and Midwives) 2014. Towards a shared understanding of terms and concepts: Strengthening nursing and midwifery care of Aboriginal and Torres Strait Islander peoples. Canberra: CATSINaM.

Department of Health 2013. National Aboriginal and Torres Strait Islander Health Plan 2013–2023. Canberra: Department of Health.

Department of Health 2015. Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–2023. Canberra: Department of Health.

DHHS (Department of Health and Human Services) 2016. Improving cultural responsiveness of Victorian hospitals:  Final Report.  Victoria: DHHS.

Johnstone, M-J. & Kanitsaki, O. 2007.  An exploration of the notion and nature of the construct of cultural safety and its applicability to the Australian health care context.  Journal of Transcultural nursing, 18(3) 247-256. DOI: 10.1177/1043659607301304

NACCHO (National Aboriginal Community Controlled Health Organisation) 2011. Creating the NACCHO Cultural Safety Training Standards and Assessment Process: A background paper. Canberra: NACCHO.

NCCIH (National Collaborating Centre for Indigenous Health) 2013. Towards Cultural Safety for Métis: An Introduction for Heath Care Providers. Canada: University of Northern British Columbia.

Nursing Council of New Zealand 2002. Guidelines for cultural safety, the treaty of Waitangi, and Maori health in nursing and midwifery education and practice. Wellington: Nursing Council of New Zealand.

Wardliparingga Aboriginal Research Unit of the South Australian Health and Medical Research Institute 2017. National Safety and Quality Health Service Standards user guide for Aboriginal and Torres Strait Islander health. Sydney: Australian Commission on Safety and Quality in Health Care.