Cultural Competency and Cultural Safety
If ever there is a prospect of writing on a topic that has kept me awake, it is this chapter. Whatsoever has gone before in this Pressbook, I turn up as a fraud here. It reminds me of my time spent teaching toxinology. There I was, all ochs and glottal stops, teaching Australians about their many venomous critters. Pretending I was an expert on brown snakes, taipans, funnel webs, red backs, Chironex fleckeri and Irukandji. I got away with it for a while but eventually I was escorted from the lecture theatre. Perhaps it comes from being male? Feeling like I can do something despite not being appropriately qualified. When I worked on road, I did attend a couple of envenomations, and I was confident with my PIT. As for what was going on in terms of neurotoxins or coagulopathy, I had not one clue. What else can I say? Basic cares! *softening* basic cares.
It comes to pass again. Teaching something I am not qualified to teach. Apart from being called a sweaty and a F.R.I.S.P. a couple of times I am going to list the examples, in no particular order, why I am not qualified to teach you about cultural competency or cultural safety:
- Every building I have ever entered I have been able to do without assistance or use of modifications incorporated into the building structure
- I have never been refused entry into any country
- Even on 12 July 2009, I thought I would have been challenged with more than a cursory glance of my passport and visa
- In fact, I’ve never been refused anything:
- Contract for services
- Voting rights
- Cultural heritage
- Health services
- Freedom to move
- Property ownership
- Political affiliation
- Thought, belief and religion
- I’ve never been:
- Stopped and searched
- Strip searched
- Been misgendered repeatedly
- Moved on
- Denied language rights
- Denied access
- Persecuted based on
- Sexual orientation
- Economic status
- The only times people thought I was a waiter or a cleaner was when I was working as a waiter or a cleaner
- Made to feel inferior
- Rounded up and given the status of persona non grata
- Declared inhuman
- Made to feel invisible
- Flee a war torn country and raped multiple times while attempting to flee
Please don’t get me wrong, I am not for one moment offering up my privilege. I am trying, perhaps clumsily, and had I’d asked anyone before I began to write this ill-advised introduction I may have thought twice and not gone ahead, to acknowledge and compare different experiences. I don’t feel I share part of a collective guilt, regret yes, but not guilt. However, my generation and each subsequent generation must embrace diversity, and collectively and unapologetically pursue equality. This to my mind are two of the most important aspects that will help people maintain a course of self-improvement: acknowledge the past but do not repeat its mistakes. Ever.
But we’re only as good as we think we are if we’re not tested. It’s funny how and when life tests undermining cultural awareness occurs. You tend to do better if you’re prepared for a test, don’t you? Sometimes life serves you up a test and you don’t get time to prepare. That’s when it happened to me, during a rugby match one of my sons was playing in. A player called another player the word that Chris Rock said there is only a singular circumstance when a white person is ever allowed to utter that word. I didn’t hear the word used during the game. I heard about it afterwards from the boy who it was used against. He told me the word he had been called. It was a shock to hear it. I was so shocked I failed to acknowledge he had been called the word and instead I focussed on the word he had been called. By the time I realised the error in my judgement, I had dropped him off at home and I didn’t see him for the rest of the season because he didn’t come back. Like I said, I don’t tend to feel guilt, but I do feel regret. This regret is that I didn’t acknowledge straight away how horrible that word made this young person feel. I regret that it was not my instinctive reaction to support him. Instead I focussed on the abhorrence of the word at the expense of how it made this young person feel. It made me realise I have a long, long way to go to understand cultural competency and cultural safety. Plus, it made me realise why I must include cultural competency and cultural safety into CSB338. What was it the author of Jonathan Livingston Seagull, Richard Bach said? Something about we teach best what we most need to learn. Yes, I think that’s it. Well, let’s hope for the best in this chapter.
- 1 Boundary Street/Road
Have you ever thought about the why some roads have the names they have? Often there are thematic similarities. Occasionally a road or street name will describe its purpose. Even if that purpose is outdated and discriminatory. This is the story of the various Boundary Roads and Streets in Brisbane and “the restriction of movements facing Moreton Bay Aborigines”.
“During the last decades of the nineteenth century Aborigines were increasingly marginalised on their own lands. Although they were allowed into Brisbane town during the day, they had, since the early 1850s, been the targets of a curfew, which was enforced after 4pm and on Sundays. Rev Henry Stobart, who arrived in 1853, remarked that the blacks seem to leave this town at one regular hour each day, and one of the boundary posts was at Cumbequepa (Somerville House) south Brisbane.131 The major demarcation south of the river operated along Vulture and Boundary streets. Charles Melton wrote that police were empowered by regulation to drive them out of town at nightfall, but because police were so greatly outnumbered by Aborigines in the town the regulation was difficult to enforce.132 By 1877 it would appear the curfew was more efficiently applied. Recalling the forced expulsion of all Aboriginal men and women at sundown, one traveller wrote: After 4pm the mounted troopers used to ride about cracking stock-whips to notify the Aboriginals to get out.133 Those whose lands lay south of the river would have retreated beyond the town boundaries to the camping areas of Woolloongabba, Dutton Park, Fairfield, Annerley and the Coorparoo watercourses.”
10.2 Cultural competence
There is unlikely a singular perfect definition of cultural competence. Cultural competence (or transnational competence) will mean different things to people. It does, however, have its roots in human rights.
Professor Juanita Sherwood offers this definition:
“Cultural competence is the ability to participate ethically and effectively in personal and professional intercultural settings. It requires being aware of one’s own cultural values and world view and their implications for making respectful, reflective and reasoned choices, including the capacity to imagine and collaborate across cultural boundaries”.
HCPs, like all client facing service professionals, need to understand the nature of social diversity and the various impacts caused by oppression based on race, ethnicity, national origin, colour, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical disability.
Every group has a culture. It’s what makes a group a group. Just because something is labelled should not prevent others from learning, engaging and growing to understand origins, evolution and dynamic. Dominance can lead to persecution and mistreatment. This is a well-established historical narrative. The transformative benefits of cultural competence ought to be a corrective solution for human rights abuses. According to Paul Pederson to be culturally competent requires the following:
- Awareness is consciousness of one’s personal reactions to people who are different. A police officer who recognizes that he profiles people who look like they are from Mexico as “illegal aliens” has cultural awareness of his reactions to this group of people.
- Paul Pedersen’s multicultural competence model emphasized three components: awareness, knowledge and skills. DTUI added the attitude component in order to emphasize the difference between training that increases awareness of cultural bias and beliefs in general and training that has participants carefully examine their own beliefs and values about cultural differences.
- Social science research indicates that our values and beliefs about equality may be inconsistent with our behaviors, and we ironically may be unaware of it. Social psychologist Patricia Devine and her colleagues, for example, showed in their research that many people who score low on a prejudice test tend to do things in cross cultural encounters that exemplify prejudice (e.g., using out-dated labels such as “illegal aliens”, “colored”, and “homosexual”.). This makes the Knowledge component an important part of cultural competence development.
- The Skills component focuses on practicing cultural competence to perfection. Communication is the fundamental tool by which people interact in organizations. This includes gestures and other non-verbal communication that tend to vary from culture to culture”.
HCPs can develop cultural competence by “gaining a broadening of perspective that acknowledges the simultaneous existence of differing realities that requires neither comparison nor judgement; being aware of likely areas of potential cross‐cultural miscommunication, misinterpretation, and misjudgement; anticipating their occurrence and have the skills to set them right”.
Cultural competency is not a blanket approach to achieving cultural safety. Providing and promoting culturally safety, discussed in the following section, requires an understanding of all issues that impact people accessing health services. Cultural and linguistic differences (CaLD) can limit people’s access to services based on language barriers. This is but one, and perhaps obvious example. Awareness and knowledge accretion by service providers may help put people in a better position despite opposition to accessing services.
10.3 Cultural safety
According to Robyn Williams, “cultural safety as: an environment that is spiritually, socially and emotionally safe, as well as physically safe for people; where there is no assault challenge or denial of their identity, of who they are and what they need”. It should follow that if a service provider is culturally competent then services users or patients will feel culturally safe. It’s not quite so simple as that. Discourse over assumption must be emphasised. Thinking you are doing a good job may not in all actuality be reflected by service users. Wherever possible courteous communication within a dialogue should assist to ensure culturally safety is achieved. A (dominant) narrative is not the sole narrative. This is present in microaggressions that people may consider harmless (phatic) conversation. Forgive, the glib example, but despite liking haggis, I don’t eat it for breakfast, lunch and dinner. Everything in moderation, after all. Now, I appreciate this is a low level issue when compared to the many atrocities faced by diverse groups who have had their legal status removed, treated as criminals or have been subjected to degrading treatment for highlighting human rights abuses. Taken as a single part, the impact of a microaggression may not be felt so keenly. Taken collectively, the impact may be felt substantially. Unsafe cultural practice is any action, which diminishes, demeans or disempowers the cultural identity and well-being of a person. Understanding the impact of the parts overall ensure people are better placed to feel culturally safe. Power differences, no matter how they are established, impact health, quality and safety for people. A health service must represent the patients it serves. Failure to achieve this means that the dominant group, no matter how well intentioned it is, will neglect to meet the requirements of cultural safety. This section ought to bear some resemblance to chapter 3. Front-line HCPs need to be able to reflect upon responses to patient groups and ensure that people are treated equally irrespective of differences and as proposed by AHPRA.
According to the Australian Bureau of Statistic’s National Aboriginal and Torres Strait Islander Health Survey, 2018-19:
“More than four in 10 (46%) people had at least one chronic condition that posed a significant health problem in 2018–19, up from 40% in 2012–13”.
Health disparities exist and persist in Australia. There are barriers that may prevent people from accessing similar services in a similar way. Factors in Australia can include but are not limited to distance and remoteness. Immigrants, refugees, asylum seekers and undocumented migrants all have different experiences of accessing services. Additionally, there will be issues accessing health if a group uses practices that are illegal and criminal such as FGM/FGC (discussed in chapter 4). HCPs often sit at the intersection between healthcare, cultural competency, cultural safety, violence against women and child protection, and this may deter people from seeking and accessing health services. Efforts must be made to eliminate the practice while at the same time health services are delivered to marginalised and vulnerable groups. The dilemma poses significant issues particularly within a framework of cultural competence and cultural safety.
Fundamental action to contribute to narrowing gaps in access to health services to groups is the ability to ask the question exposing HCPS to self-examination, which is am I doing everything I can for my patient. Although you treat your patients with courtesy, this may not engender a feeling in your patient that they are being supported from a cultural perspective. It is about considering their experiences and understanding how those experiences relate to their access to healthcare. HCPS must recognise and respect agency. Challenge assumptions, deconstruct stereotypes and eliminate prejudicial bias from your care. Emphasise your professional self-preservation but not at the expense of another’s dignity.
Finally, discussing race, sex, age (just some examples, and by all means not the only examples a person can feel discriminated) is not by default racist, sexist or ageist. Be prepared to have conversations without fearing condemnation. Understanding is key to development and growth. Do not deny people their experience because you have not shared this experience with them. Acknowledge and move forward jointly. Be prepared to advocate for your patient and always challenge your own responses. Aim to promote strong healthcare relationships and bonds within the community you work and serve.
10.5 Final thoughts
I tried to conceive a myriad of ways to teach cultural competency and cultural safety in this Pressbook. I listened recently to an interview with novelist, Zadie Smith where she talked of race labour. The labour she talked about is not limited to race, of course. It applies to any situation whereby a spokesperson of a marginalised group is called upon to provide commentary to facilitate an audience’s understanding of a topic. The notion of labour in this sense is based upon a representative individual discussing a topic that ought to be ostensibly obvious. Despite this, individuals from marginalised groups are called upon to deliver commentary to anyone, despite possessing basic skills of critical analysis and cultural competency, should be able fathom on their own. People need to educate themselves and be prepared to challenge their beliefs and be prepared to scrutinise and test their beliefs and behaviours, for example, to establish whether their beliefs and behaviours are compatible with cultural competency. Being open to evaluation and revision promotes a growth mindset that should, hopefully, contribute to an appropriate level of cultural competency.
Cultural competency and cultural safety take effort. This is not a deterrent, instead it ought to serve as an incentive. Ensuring all people have the same access to services should not be beyond the grasp of Organisation for Economic Co-operation and Development (OECD) states. I am grateful for my privilege but is has taken me a long time to realise that any success I have achieved has been a product of a fundamentally unfair system. This has not been a definitive guide to cultural competence and cultural safety for paramedic and nursing students. It has been an introduction. Learning about cultural competence and cultural safety is an iterative process. It needs to form part of continuing professional development. This is a topic that will require revisiting again and again. Don’t always look to others to be responsible for educating yourselves on cultural competence and cultural safety. Instead, take the lead. Promote in yourself a policy of inquiry and growth. Don’t be afraid to ask questions because it may shine a light on perceived ignorance. Don’t be afraid to talk about race, gender, identity, disability, orientation or religion because it might invite accusations of discrimination. Do not diminish, demean or disempower the cultural identity and well-being of a person. And do not be afraid to learn and grow to enable relationships to develop and strengthen. We are on the cusp of an evolutionary shift. Now, more than ever, is the time to develop dialogue, to progress the conversation and be willing to expose values to scrutiny so we can collectively deepen our common bonds and reject values that have held back too many for too long. Additionally, don’t be afraid to call out practices that harm vulnerable members of all our communities. Disparity is a gulf that needs to be bridged and this has never been more relevant to healthcare than it is currently.
I haven’t done this topic justice. It impossible to write about this without directing inquiry inwards. During the writing process, I have reflected on my professional values in relation to cultural competency and cultural safety. I have a long way to go. The key is growth and rejection of any resignation that things will not improve for marginalised groups and vulnerable populations. Structures that have allowed some groups to flourish over others need to be replaced. This will take time and a collective will. A process must be put in place to acknowledge differences with the overall aim to address inequalities that have perpetuated for millennia. Commonality and respect for diversity are two foundational cornerstones on which a new structure of equality must be shaped.
10.7 Recommended further reading
Mkandawire-Valhmu, L. (2018). Cultural safety, healthcare and vulnerable populations: A critical theoretical perspective. Abingdon, Oxon Routledge.
- If you don’t listen to it all, at least listen from 19 minutes and 15 seconds. ↵
- https://www.slq.qld.gov.au/blog/aboriginal-boundary-posts. ↵
- https://metrosouth.health.qld.gov.au/sites/default/files/content/pah-aboriginal-history.pdf. ↵
- https://www.sydney.edu.au/nccc/about-us/what-is-cultural-competence.html. ↵
- https://cdn.ymaws.com/www.naswaz.com/resource/resmgr/imported/CulturalCompetence.pdf. ↵
- QUT’s School of Public Health and Social Work. ↵
- Williams, R. (1999). Cultural safety--what does it mean for our work practice? Australian and New Zealand Journal of Public Health, 23(2), 213–214. http://search.proquest.com/docview/215708712/. ↵
- https://www.abs.gov.au/ausstats/abs@.nsf/mf/4715.0?OpenDocument. ↵