5
Cultural Safety Considerations
Session objective: To promote open dialogue on cultural safety considerations across professions that decision makers need to be aware of when selecting paths for the role of learners in the health care system during a crisis.
Looking back at the previous three sessions, Erin Patel, acting chief of health professions education for the Office of Academic Affiliations at the Veterans Health Administration, noted the progressive learning taking place. She reviewed the third workshop session, which was organized and run by a group of 16 students and trainees who provided their perspectives on learning during a crisis, both in person and virtually. Patel said:
I will say that learners gained—and are [still] gaining—valuable skills with online training and simulation, but it is not yet known how missing in-person experiences will affect learner skills and competencies or how it will affect learners’ views of themselves during future crises and whether decisions made during this public health crisis will set a precedence for how health professional education will react to future crises, regardless of whether the crisis is another pandemic, a natural disaster, a power outage, or most likely a crisis we can’t predict.
This background led to the fourth session, which focused on an important piece of the decision-making process: cultural safety. Whether considering learners’ roles in the health system, the educational system, or their work with patients and communities, decision makers must be aware of cultural safety issues. After reflecting on the day’s session objective, Patel handed the microphone to Robert Cain, president and chief executive officer of the American Association of Colleges of Osteopathic Medicine, who reviewed discussions from previous workshop sessions related to the decision tree (see Appendix B) and introduced the session moderator who also provided context for the topic of cultural safety.
DEFINING CULTURAL SAFETY
Lisa VanHoose, associate professor and program director in the Physical Therapy Department at the University of Louisiana, began the session by sharing a framework for cultural safety and humility, developed by the First Nations Health Authority (Figure 5-1). This concept of cultural safety, she said, was created to talk about how care can be delivered in a way that allows for shared decision making.
Cultural safety, VanHoose pointed out, is the culmination of several other competencies related to culture. First is cultural awareness, which is the ability to identify differences between oneself and another person. Cultural sensitivity is the ability to understand that there is more than one perspective, and cultural competency is how practitioners can consider other people’s lived experiences and incorporate these into their practice and patterns as health care providers. Finally, cultural humility is the ability to recognize other perspectives and to respect that other opinions or value
SOURCE: VanHoose presentation, November 11, 2021.
systems are valid. The idea of cultural safety, she said, stemmed from the desire to improve care delivery and to offer culturally tailored care, but recently it has been expanded to health care more generally, and to the field of education as well. Cultural safety involves considering how to dismantle the power structure in order to create sustainable models that recognize the end user, said VanHoose.
The COVID-19 pandemic has presented an opportunity to consider cultural safety in the context of clinical learning, she noted. A 2021 paper on the effect of the pandemic identified four domains of the clinical learning environment: personal characteristics and experiences of the learner, social relationships, organizational culture, and the institution’s physical and virtual infrastructure (Triemstra et al., 2021). VanHoose asked workshop participants to think about their organization’s response to COVID-19, and to consider which of these four domains was the first priority during the early days of the pandemic. She further asked participants to think about whether this prioritization was rooted in cultural awareness, sensitivity, competency, or safety. In other words, was the decision made with awareness of cultural differences and recognition of different perspectives, or did the institution “come from a place of safety” and “engage the learners in this decision-making process”?
VanHoose shared an illustration from the National Collaborating Centre for Indigenous Health that compares cultural awareness, sensitivity, competence, and safety. She remarked on how the process begins with being aware of one’s own culture, and noted that people from the dominant culture often struggle to acknowledge they are part of a specific culture. In this definition of cultural safety, VanHoose acknowledged three main aspects: (1) using a systematic approach that acknowledges the power differentials inherent in health care, (2) removing institutional and cultural barriers to care delivery, and (3) building an inclusive, client-centered service delivery model.
Applied to education, she said, cultural safety requires adaptive teaching—that is, acknowledging and addressing the different needs, experiences, and learning styles of learners. Cultural safety “places an obligation on the provider or educator to offer safe service as defined by those receiving the service.” VanHoose emphasized the paradigm shift that is inherent in this model. Traditionally, the educator is in the place of power and makes decisions based on his or her cultural perspective and value system. With cultural safety, the power shifts to the learner. VanHoose explained how this process involves a collaboration between educator and learner, and does not simply rely on the educator’s view of what the learner wants. Cultural safety requires “self-examination, openness, and flexibility as well as a concerted effort not to blame victims of historical and social marginalization,” she said (Curtis et al., 2019).
Before workshop participants divided into breakout groups, VanHoose shared five principles of cultural safety to consider:1
- Personal knowledge: Ask what the cultural identities and needs of the person are.
- Partnership: Solve problems collaboratively.
- Protocols: Learn and use cultural forms of engagement. Consider whether these forms are in agreement or disagreement with the institutional or disciplinary culture.
- Process: Frequently engage and assess cultural responsiveness.
- Positive purpose: Ensure a good probability of achieving the recipient’s goals.
Additionally, she encouraged participants to keep in mind three questions while thinking about cultural safety in the context of the clinical environment during COVID-19:
- Who is in the center of the decision making during the crisis?
- Who is serving as the decision maker, and why?
- How do we create culturally safe environments for learners, patients, and employees?
FACTORS THAT SUPPORT CULTURAL SAFETY
Following those introductory remarks, workshop participants divided into groups to discuss factors that do or do not support cultural safety. To ensure the groups would be safe environments for discussion, VanHoose pointed out the discussions would not be recorded nor would there be reports on what was said. Instead, following group discussions, the leaders from each group joined in a roundtable discussion on the considerations of cultural safety when making decisions about learners in the health care system during a crisis.
The participants reconvened, at which point, VanHoose moderated a discussion with the students and trainees who collaboratively led the small group discussions with educators. She asked them to share comments on cultural safety considerations. Tiffany Mathis, Morgan State University, master of social work student, responded first saying her group’s discussion focused on dismantling the power structure, understanding the dynamics of power between faculty and learners, and considering how to develop a more systemic approach that includes the learner “early and often.” Mathis noted how there is often an initial “stop the bleed” effort during a crisis,
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1 See http://ecdip.org/culturalsafety (accessed July 6, 2022).
adding that learners should be involved and engaged in decision making as soon as it is safe to do so.
Jessica Johnson, Kentucky College of Optometry, class of 2023, emphasized the importance of strong communication and transparency in decision making. She explained that while some people may or may not have agreed with a final decision, administrators tried to make sure they fully explained the process and the reasons for their decision to those affected by the decision.
A major discussion point of the third group, said Joanne Michelle Ocampo, a doctor of public health candidate from Columbia University, was recognition of learners as a resource in building—and perhaps cocreating—culturally safe and responsive spaces. Learners have a variety of intersecting perspectives, cultures, and experiences that can inform the creation of a learning environment.
VanHoose asked the group leaders to share aspects of their own cultures and their own experiences in clinical or community learning environments. Ocampo responded that she identifies as Norwegian-Filipina, and having an Asian background while living in New York City at the height of the pandemic was challenging because of the racialized aspects of the pandemic discriminating against Asian and Pacific Islander communities. As both a learner and a worker in the public health response during COVID-19, she expressed her wish for better recognition of the nuances within the student body, noting that different learner communities will have different needs and resources. An area for improvement, she said, would be for faculty and administrators to consider the perspectives and needs and resources of communities “not just on the outside of our academic and clinical institutions, but also on the inside.”
Johnson shared about her culture and experiences saying she is a White woman from a poor region of Kentucky, working in rural Appalachia. There are sometimes misconceptions about people with her accent, both for patients and physicians. She asked rhetorically, “Do I sound like I’m capable to treat people?” and admitted feeling lucky to be working in a region where people do trust her. She said some of her peers who are working in other parts of the country have struggled to be taken seriously as providers because of their background and accent.
As a Black woman at a historically Black college, Mathis felt a sense of cultural safety, though she acknowledged the student body is not monolithic. The school was sensitive to students’ needs, strove to keep students safe, and ensured all students could participate in remote learning or experiential opportunities. Being an older, nontraditional student does have some unique advantages, she noted. For example, Mathis was able to afford whatever equipment and new supplies she needed. The school, for its part, encouraged students to work together through the pandemic—and the social justice
issues that were co-occurring—while acknowledging students’ “exhaustion.” Educators and administrators worked with the students to ensure successful learning, although one thing could have been done better, said Mathis. In her view, they could have included learners earlier and more often in the process of making decisions about learning and clinical experiences.
VanHoose then asked the group leaders, “If you were president of your institution, what is one thing you would incorporate into the structure to improve cultural safety for your learners?” Mathis began by reiterating the importance of including students early and often. Students could even be involved in planning discussions that are held before a crisis happens, which would be a valuable learning opportunity. Ocampo said she would create cultural spaces where faculty and learners could discuss what it would take to have culturally safe and responsive spaces in education and practice. By bringing together voices from across the power spectrum, she said, the needs, resources, and perspectives of the group might be more likely to be heard by decision makers in the institution.
VanHoose said she liked this idea because it gives learners power within the educational system and acknowledges them as more than just their “tuition balance.” Johnson concurred with the need for more input and involvement of learners. When she and her classmates were asked to volunteer in their community during the early days of the pandemic, it felt like a burden. Learners had to attend additional training and find time in their already-packed schedules to volunteer. Johnson suggested that instead, learners could be involved from the beginning and could form a group of “enthusiastic” volunteers for planning a service program together. By coming together and drawing on the strength of the school community, said Johnson, it could “lighten the load” and restructure the mindset of volunteering. VanHoose underscored the learners’ reflections saying, “Make space for what we value.” If a school wants students to volunteer in the community during a crisis, she clarified, it needs to shift workloads and make space so these experiences are not a burden.
REFERENCES
Curtis, E., R. Jones, D. Tipene-Leach, C. Walker, B. Loring, S-J. Paine, and P. Reid. 2019. Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal of Equity and Health 18:174. https://doi.org/10.1186/s12939-019-1082-3 (accessed July 20, 2022).
Triemstra, J. D., M. R. C. Haas, I. Bhavsar-Burke, R. Gottlieb-Smith, M. Wolff, A. V. Shelgikar, R. V. Samala, A. L. Ruff, K. Kuo, M. Tam, A. Gupta, J. Stojan, L. Gruppen, and H. Ellinas. 2021. Impact of the COVID-19 pandemic on the clinical learning environment: Addressing identified gaps and seizing opportunities. Academic Medicine 96(9):1276-1281. https://doi.org/10.1097/ACM.0000000000004013 (accessed July 6, 2022).
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