Cultural Safety Exploring the Applicability of the Concept of Cultural Safety to Aboriginal Health and Community Wellness

Organizational and Systems Leadership Change Project
October 18, 2020
this is a research paper 3
October 18, 2020

Cultural Safety Exploring the Applicability of the Concept of Cultural Safety to Aboriginal Health and Community Wellness

Cultural Safety Exploring the Applicability of the Concept of Cultural Safety to Aboriginal Health and Community Wellness

Simon Brascoupé, Department of Sociology and Anthropology, Carleton University

Catherine Waters, BA, MA

ABSTRACT The goal of the research paper is to explore both the concept of cultural safety and its practical implications for policies and programs designed to improve the health of Aboriginal people and the wellness of Aboriginal communities. The paper demonstrates the concept of cultural safety can shift from a being a tool to deliver health care services to individuals to a new and wider role. The concept of cultural safety can have a significant impact the way policy and services are developed at an institutional level in fields such as health, education, the courts, universities, and governance (both First Nations and other types of government). Four case studies at the end of the research paper show how cultural safety has helped communities at risk and in crisis engage in healing that led to lasting change. The research paper, defines cultural safety and how it differs from cultural competence or trans-cultural training and practices; shows why it’s important to move from the concept of cultural safety to the outcome of cultural safety, namely the success of an interaction; explores the idea of a shift from cultural safety for individuals to cultural safety at institutional and policy levels; and provides recommendations in five areas.

KEYWORDS Colonization, cultural safety, healing and wellness, historical trauma, social determinants of health

INTRODUCTION

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1. Introduction and definition

This paper describes and analyzes the concept of cultural safety as it pertains to Aboriginal policy and assesses its usefulness as a means of designing and developing government policy and service delivery. It seeks to draw together a range of literature sources to assess the applicability of cultural safety in a Canadian context.

The aim is to understand First Nations communities at risk and in crisis and the effectiveness of programs designed to address their issues. While focused on cultural safety, the paper broadens to consider other connected issues, as well as the wider determinants of health within

a holistic and community-based context. The focus will be on conclusions in the form of lessons learned, best practices and recommendations for government departments, policy- makers, researchers, scholars, and community members.

The concept of cultural safety evolved as Aboriginal people and organizations adopted the term to define new approaches to healthcare and community healing. Much of the literature confirms that a definition of cultural safety should include a strategic and intensely practical plan to change the way healthcare is delivered to Aboriginal people. In particular, the concept is used to express an approach to healthcare that recognizes the contemporary conditions of Aboriginal people which result from their post-contact

 

 

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history. In Canada, Aboriginal people have experienced a history of colonization, and cultural and social assimilation through the residential schools program and other policies, leading to historical trauma and the loss of cultural cohesion. The resultant power structure undermined, and continues to undermine, the role of Aboriginal people as partners with healthcare workers in their own care and treatment. In the context of healthcare delivery, culturally unsafe practices have been defined as “any actions that diminish, demean or disempower the cultural identity and well-being of an individual” (Cooney, 1994). As this definition suggests, the term ‘cultural safety’ has a wide potential of application to other areas of government policy and service. In this sense, the concept of cultural safety represents a potent tool in the development and delivery of policies and services relating to Aboriginal people, not just in the health field, but also other areas of social policy.

However, the generality of this definition also serves as a warning to policy-makers: the precise meaning and implications of the concept of cultural safety remain vague and elusive. To be able to introduce cultural safety into policy and delivery, policy-makers must understand what cultural safety fundamentally means, the difference it makes to policy development and delivery, and where cultural safety lies conceptually and in practice in relation to previous considerations of cultural difference.

This paper seeks to clarify and deepen the definition of cultural safety, and explore practical strategies, approaches and lessons learned that address the key drivers of risk and crisis in First Nation communities. By considering the social and cultural implications of Aboriginal post-contact history, the concept of cultural safety can contribute to a greater understanding of the origins of these crisis situations and how policies can be developed to address them. In the past three decades, there have been some promising indicators of success in community development, such as the healing and wellness movement in Canada and the research results of the Harvard Project (Kalt, 2007). From a policy perspective, whole communities have benefited from policies and practices that might be described as ‘culturally safe’, bringing cultural considerations into policy development, strategic planning and training. Some communities have achieved remarkable results through innovative social policies, good governance, and sensitive community development. Through these and other initiatives, we are beginning to understand how cultural safety and the resulting trust can play a role in wider social and economic development. The case studies in Appendices A to D provide examples of initiatives undertaken by Aboriginal people within their communities to improve health and well-being following the teachings

and symbols of Aboriginal culture. By reviewing the relevant academic literature, and

investigating reports and examples on culturally safe practices, the paper looks at what the concept of cultural safety offers Aboriginal people as they work to regain control over their communities in crisis, both at the community and individual level. It is important to locate the concept of cultural safety within the context of cross- cultural relationships, between Aboriginal service-receivers and non-Aboriginal service deliverers, and to consider how the concept affects relationships, power structures and trust. In the historical context of mistrust and trauma caused by colonization, the building of trust within cross-cultural interaction is critical to policy effectiveness (Wesley- Esquimaux, 2004). This paper considers the changing power structures underlying the growth of trust, and where responsibility lies for deciding if a successful trust relationship has been achieved.

Unfortunately, statistical evidence of the benefits of cultural safety is scarce. The most concentrated investigation of the applicability of culturally safe practice is found in literature from the New Zealand and Australian health care field, largely focused on nursing. Even here, the evidence is largely qualitative and anecdotal. The body of literature examining wider issues of culture in health care delivery, focusing in particular on cultural competence, is more extensive and shows that cultural consideration improves health outcomes.

Still less evidence exists on how the concept of cultural safety can be used in relation to communities at risk and in crisis. The studies on nursing and midwifery focus on the interaction between non-Aboriginal health care professionals and Aboriginal patients; they do not extend the discussion of cultural safety to wider issues of social well-being, including the failings of the educational system, drug and alcohol abuse, family dysfunction, and violence. This link to communities in crisis in a general sense may be the subject of more focused examination in academic and professional institutions in the future. A culturally safe delivery system could strengthen the capacity of communities to resist the stressors and build resilience to those forces that push them from risk to crisis.

Cultural safety developed as a concept in nursing practice in New Zealand with respect to health care for Maori people (Wepa, 2005; Williams, 1999). It develops the idea that to provide quality care for people from different ethnicities and cultures, nurses must provide that care within the cultural values and norms of the patient. As we will explore in more detail, the concept of cultural safety challenges the previously accepted standard of transcultural nursing by transferring

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the power to define the quality of healthcare to Aboriginal patients according to their ethnic, cultural and individual norms. Thus, cultural safety as a concept incorporates the idea of a changed power structure that carries with it potentially difficult social and political ramifications (Ramsden, 2002; Cooney, 1994). The introduction of the concept of cultural safety to the debate on cross-cultural healthcare was significant: it questioned and challenged the concept of cultural competence and, by bringing in the notion of safety, it extended the debate by focusing less on the benefits of cross-cultural awareness and sensitivity, and more on the risks associated with their absence.

Canadian practitioners have contributed to the idea of culturally safe practices through community-based institutions, approaches and traditions. There is growing and promising literature demonstrating a link between cultural safety and healing methodologies, which could provide indicators of community health or risk for First Nations communities at risk. The success of healing communities at risk and in crisis, at both the individual and community levels, may lie partially in understanding the distinction between the different concepts of cultural consideration, their relation to each other and their validity in practice.

One of the challenges for Aboriginal communities is deciding their policy priorities, for example, economic development, social deprivation, housing, education, or health. Most research examining issues of practical concern and lessons learned takes its results from communities that are successful. While informative and useful, this research does not pay sufficient attention to communities at risk or in crisis. Therefore, this literature search will take a fresh look at the promising analysis of the prerequisites or starting points for communities on their healing path and how healing begins. As a community strategy, how do you focus on the determinants of health? How do the broader determinants of health play a critical role in community development? What can we learn from communities that have, as a starting point, focused on the broader determinants of health through community healing? If the community is at risk, how do you assess where a community is on its own continuum of healing? And what are the next steps? In addressing these questions, the paper aims to discover the conceptual robustness and practical value of cultural safety as a tool for improving community and individual well-being.

Finally, this paper addresses the relevance of programs and services to the values, traditions, beliefs, and practices of Aboriginal people. The issue of culture and the degree to which it can and should be part of policy design and implementation are complex, but increasingly it is

recognized and accepted that policy cannot be effective if it does not acknowledge and take some account of the cultural context in which it is applied. The idea that government policy may fail or its effects be mitigated by cultural misunderstandings or ignorance presents the imperative behind the concept of the cultural safety.

2. Literature Search The literature search includes academic literature, focused both on health and indigenous cultures, grey literature and the Internet. The timeframe for the search concentrates on the past ten years, from the first serious research on cultural safety, and draws on significant contributions to the canon beyond fifteen years. The potential scope of the subject makes a thorough examination of all sources impossible. However, by tracing the development of the research through the many sources of information, it is possible to see the progress of thinking on this subject and identify trends and gaps in the research. The academic health and indigenous literature, including various electronic databases from selected national, international and indigenous journals, the grey literature research including Aboriginal, government and other reports, studies, etc. An Internet search included national and international literature available on the internet (the Google search identified 6,860,000 citations for “cultural safety;” 455,000 citations for “cultural safety in health care,” and 273,000 citations for “cultural safety Canada”) presented a comprehensive review of relevant academic and professional research.

3. Cultural Competence and Cultural Safety Evidence Base The evidence base for cultural competence and cultural safety is being examined from the perspective of quantitative, qualitative and traditional research methods. Cultural competence research provides a foundation for cultural safety; for example, Ramsden (1992) conceptualizes it as a continuum of moving from cultural awareness to cultural competence to cultural safety. Since cultural competence is more broadly practiced around the world and has been in existence longer, there is more research in the literature. Since cultural safety is a relatively new concept and less understood outside indigenous experience, there is less research and mostly of a qualitative nature.

In a major study of the cultural competence evidence- base in health care, the National Center for Cultural Competence found some promising studies supporting health outcomes and patient satisfaction (Goode et al., 2006). They identified primary research articles on health

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outcomes and well-being found in Medline from January 1995 to March 2006. The study found that health outcomes and patient satisfaction evidence were very promising but in the early stages of development. They also found that a decrease in the liability of providers or organizations was showing some strong preliminary evidence. Another study by John Hopkins University from 1980 to 2003 found excellent evidence that supported cultural competence training as a strategy for improving the knowledge, attitudes and skills of health professionals (Beach et al., 2005). The study also found good evidence that cultural competence training positively impacts patient satisfaction. A search for current cultural competence literature to December 2008 in PubMed identified 882 papers, including the Beach study, but no other recent evidence-base studies. In summary, while the current evidence shows great promise for cultural competence, there is a need for better-designed studies (Goode, Dunne & Bronheim, 2006; Beach et al., 2005) to advance the evidence base.

The challenge is to extend the understanding of the role of cultural competence in health-care delivery to the concept of cultural safety, by distinguishing between these concepts and understanding what difference cultural safety brings to policy outcomes. Research on cultural safety is an emerging field; no quantitative and a few qualitative articles were found, a few calling for more evidence based research. Research recognizes that a shift is occurring, that in New Zealand nursing incorporates cultural safety (NZNC, 2005), and nursing is moving towards cultural competence that incorporates some aspects of cultural safety (Salimbene, 1999). Studies in Australia found that cultural safety provides a useful framework to improve the delivery of services to Indigenous peoples (Kruske, 2006). Cultural safety and cultural competence are key concepts that have practical meaning for Indigenous people. They form the basis for effective patient-centred care and the professional advocacy role of the general practitioner (Nguyen, 2008). In response to the lack of evidence-based research on cultural approaches, Anne McMurray (2004) argues for the development of an evidence-based approach in Australia that recognizes that health and illness are socially determined. This requires the involvement of individuals, families and communities; a link between knowledge and caring; and the recognition that culture contributes to the shaping of health behaviours and health outcomes. In Canada, there are a few studies by scholars (Smye & Browne, 2002) that explore how Aboriginal peoples experience culturally safety, to deepen the understanding of the effectiveness of cultural safety tools and interventions in nursing practice. Other researchers, like Jessica Ball (2007a), ask “How safe did the service recipient

experience a service encounter in terms of being respected and assisted in having their cultural location, values, and preferences taken into account in the service encounter?” (Ball, 2007a, p.1), explicitly linking service delivery to cultural respect and awareness.

These examples demonstrate part of the difficulty in understanding cultural safety: as a concept, it emerges as a distinct paradigm shift from the concept of cultural competence; but as a practical tool, it appears less as a shift in direction but rather as a further step on a continuum of cultural consideration by practitioners. This duality of meaning and direction between the academic concept and the practical tool will be explored in greater depth.

From the perspective of traditional knowledge, the evidence base for cultural safety is ancient and imbedded in traditional teachings such as the medicine wheel (Brant Castellano, 2008). An evaluation of the Aboriginal Healing Foundation’s (AHF) 140 plus projects implicitly identified cultural safety as critical to healing, and that relationships based on acceptance, trust and safety are the first step in the healing process (AHF, 2003a, 2008). In her analysis of the evidence, Marlene Brant Castellano found:

The evaluation approach adopted was to look for evidence of individual progress along a healing continuum and increased capacity of communities to facilitate that progress. Research results reveal the multiple layers of trauma laid down in the lives of Aboriginal peoples over generations and the path traversed by individuals and communities in recovering capacity for a good life (AHF, 2008, pp. 389-390).

This is consistent with the findings of cultural safety in New Zealand, where establishing and maintaining trust was a prerequisite to negotiating and delivering culturally safe care (Crisp et al., 2008). However, a search through PubMed for current “cultural safety indigenous” research literature identified 156 papers of which none had evidence- based research. In short, though there is significant research on cultural safety in individual healthcare delivery and in Aboriginal community healing projects, there is virtually no broad quantitative evidence to support the considerable qualitative exploration. In addition, the breadth of the definition of the term cultural safety as it is used in much of the literature, explicitly or implicitly, necessarily widens the scope of the literature search.

Finally, no cultural competency and safety research was found that focused explicitly on communities at risk or in crisis. Furthermore, the literature on indigenous

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communities’ development is focused on best practices, lessons learned and innovation. There is some research on communities in crisis and at risk, such as studies of the dramatic turnaround of Alkali Lake and Hollow Water First Nations. The literature clearly demonstrates that there is evidence that healing strategies, with safety as a cornerstone, work to move communities in crisis along the healing path to emerging healthy communities (Lane et al., 2002). In a qualitative evidence-based study, Thomas (2003) argues for a cross-cultural approach that mergers western clinical practices with Aboriginal cultural dimensions as an appropriate strategy to further the healing journey of Aboriginal people.

This paper begins to map out the link between cultural safety and communities at risk or in crisis. Further research and work is needed to demonstrate how cultural safety theory contributes to community development strategies in supporting communities at risk and in crisis. However, it is very promising to apply what is now known and understood about cultural safety to community-based development strategies and, as this paper indicates, is being applied in a number of innovative case studies.

CULTURAL SAFETY AND POWER

Throughout the literature, there is considerable reference to the concept and practice of cultural competence. This appears to represent a high-water mark of cultural understanding demonstrated by health-care professionals and, as the literature reveals, is taught and measured as a function of knowledge and understanding of Aboriginal culture by practitioners. Often, references to cultural safety in practice are made in relation to cultural competence, as an extension of and improvement to competence. Thus, cultural competence and cultural safety are both represented as points on a continuum of cultural approaches.

Elsewhere, the literature reveals a different understanding of cultural safety as a ‘paradigm shift’, 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.

We will now consider these two conceptualizations of cultural safety.

1. The culture continuum or paradigm shift? One way to understand the concept of cultural safety and to distinguish it from other cultural reference terms is to situate the concept on a continuum. This demonstrates where cultural safety is situated in terms of negative approaches ranging to the positive. This is a linear depiction of the continuum:

Each of these degrees of cultural awareness and accommodation represents steps in the process of attuning government to the people it governs, and institutions and individuals to the people they serve. On the negative end of the continuum, where cultural destructiveness and cultural incapacity lie, we can see the roots of colonization. The Canadian federation, constructed in 1867 to accommodate the rival ‘founding nations’ of English and French Canada, must now adapt to its highly diverse multicultural population with immigrants from all over the world, and to its responsibility for the treatment of Aboriginal peoples. It might have been expected that a young country so attuned to diversity would have shown a more enlightened approach to First Nations and greater respect for ancient indigenous cultures. However, the paternalistic legislative and policy stance, and discriminatory attitudes towards Aboriginal people meant that too often western policy deliberately or inadvertently ignored or actively destroyed the languages, cultures and traditions of Aboriginal peoples.

On the positive side of the continuum, beginning with ‘cultural pre-competence’ and ‘cross-cultural sensitivity’, there is growing awareness and recognition of the cultures of Aboriginal people. This is an educational phase where government and service providers grow in competence in applying cultural understanding to the services they deliver to Aboriginal people. When cultural safety is reached on the continuum, the result is a transformation of the relationship between the provider and Aboriginal peoples, where their needs and voice take a predominant role. Ramsden envisaged cultural safety as the final outcome of this learning process (NAHO, 2006b). In effect, the continuum shows the concept and practice of cultural safety as based on cultural competence (where the measure of competence lies with knowledge of the health-care professional) with the significant addition of the role and consequent power of the Aboriginal patient in the determination of the relationship.

The following depiction of the cultural safety continuum shows it in circular form, with each spinning out and away from the destructive policy origins.

Cultural Safety Continuum (Brascoupé, 2008) Arriving at an understanding of the concept of cultural

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safety is a journey of self-awareness on this continuum. According to Irihapeti Ramsden, the Maori nurse and educator who developed the concept in her doctoral thesis in 2002, cultural safety is the ultimate goal in a learning process, starting with cultural awareness of a patient’s ethnicity and, in culturally safe practice, growing concerns with “social justice … and nurses’ power, prejudice and attitude” (Ramsden, 2002, p. 5). In other words, Ramsden turns the focus of cultural safety away from the cultural understanding and knowledge of the health care worker and onto the power inherent in their professional position. She seeks to redefine cultural safety from a transformative point of view of the Aboriginal person receiving care; the determination of success is by the recipient, who defines the care received as culturally safe, or not.

Ramsden effectively combines the practical and the theoretical conceptions of cultural safety by depicting it both as an extension of cultural competence – where the knowledge and learning of the non-Aboriginal practitioner continues to play a crucial part in the relationship with the Aboriginal patient – and as a radical and explicit departure from it. This dual approach, stressing both knowledge (through cultural competence) and power (through cultural safety), is very attractive, as it depicts the transformation of the relationship through a combination of both conceptual and a practical change.

In the University of Victoria course on cultural safety, the issue of power as central to the concept of cultural safety is reinforced:

… the recognition that we are all bearers of culture and we need to be aware of and challenge unequal power relations at the individual, family, community, and societal level. There are important differences between cultural safety and the following concepts which are closely aligned with cross-cultural models (University of Victoria, retrieved Nov. 2008, p. 1).

Cultural safety as depicted on the culture continuum is evidently the most advanced concept in terms of practical relevance to the design and delivery of government and institutional policy. The term implies the reversal of cultural danger or peril, where individuals and communities may be at risk or in crisis. The concept entails not just the agreement and understanding that cultural differences matter in social and health policy delivery, but also the need to make a real difference in methods of delivery and the ultimate effectiveness of the policies. In other words, through cultural safety, the power of cultural symbols, practices and beliefs extends political power to the Aboriginal people. Cultural safety is not just a process of improving program delivery; it

is also part of the outcome. Scholar Jessica Ball (2007a) supports this view of

cultural safety as an outcome, but views cultural safety as a departure from cultural competence, rather than an extension of it. In essence, she sees a link between cultural sensitivity and cultural competence, but not between these concepts and cultural safety. She stresses that, while the responsibility for cultural competence lies with the service provider, cultural safety turns this on its head, transferring the responsibility (and the power) of determining how successful the experience was to the service recipient. Thus, Ball effectively appears to reject the view of cultural safety on a continuum, regarding it more as a paradigm shift in the relationship.

Unlike the linked concepts of cultural sensitivity or cultural competence, which may contribute to a service recipient’s experiences, cultural safety is an outcome. [Emphasis the author’s] Regardless of how culturally sensitive, attuned or informed we think we have been as a service provider, the concept of cultural safety asks: How safe did the service recipient experience a service encounter in terms of being respected and assisted in having their cultural location, values, and preferences taken into account in the service encounter? (Ball, 2007a, p. 1).

Ball goes on to describe five principles necessary for cultural safety:

• Protocols – respect for cultural forms of engagement.

• Personal knowledge – understanding one’s own cultural identity and sharing information about oneself to create a sense of equity and trust.

• Process – engaging in mutual learning, checking on cultural safety of the service recipient.

• Positive purpose – ensuring the process yields the right outcome for the service recipient according to that recipient’s values, preferences and lifestyle.

• Partnerships – promoting collaborative practice. (Adapted from Ball, 2007b, p. 1)

Fundamentally, the conceptualization of cultural safety as a step on a continuum or as a paradigm shift rests on the role of power in the relationship. The steps on the linear continuum or the concentric circles effectively depict the responsibilities of the service provider in the relationship. The conceptualization of cultural safety as a paradigm shift

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focuses on the role of the recipient, not as a passive receiver of services, but a powerful player in a relationship. In essence, the differences between the two conceptualizations of cultural safety turn on the notion of power in the relationship and the balance of the two roles within it.

In the writings of Ramsden (1999, 2002), Cooney (1994), and Wepa (2004), the authors consider the issue of power in cultural safety, as a transfer of power from the service provider to health care recipients. They explicitly recognize the power imbalance between non-Aboriginal nurses trained in western medicine over Aboriginal patients and locate it within the broader dominant power structures in society (Ramsden, 2002, p. 110). However, the argument does not extend to what specific challenges such a power transfer might bring, and why medical practitioners might actually avoid the term cultural safety because of the political implications (for example, Durie, 2001). Fear of the power implications of cultural safety could result in the concept being reduced or diluted to become “just an educational tool, powerless in terms of cultural change” ( Jackson, quoted in Ramsden, 2004, p. 176), in effect, a synonym for cultural competence.

In their article on culturally safe nursing practice and Aboriginal peoples, Stout and Downey (2006) argue that the political challenges are real and encompass a wide set of issues that fall under an umbrella of ‘health’. They state that a genuinely culturally safe health process involves questions about the underlying research supporting the health processes, the information gathered and held on the health and social conditions of Aboriginal individuals, and the redefinition of some conditions as diseases, including historical trauma. The context of the interaction between the non-Aboriginal nurse and the Aboriginal patient is built upon structural, institutionalized inequality. To counter this inequality and to ‘indigenize’ the knowledge base, Stout and Downey cite the introduction of the principles of ownership, control, access and possession (OCAP) into the Canadian debate. The OCAP principles are built upon Aboriginal claims for genuine self-determination. They include:

• Ownership: a community or group owns information collectively in the same way that an individual owns his or her personal information.

• Control: affirms that Aboriginal communities are within their rights in seeking control over all aspects of the research process.

• Access: Aboriginal peoples must have access to information/data about themselves and their communities, regardless of where it is currently

held. The right for Aboriginal communities to manage and make decisions regarding access to their information and resources.

• Possession: Actual physical control of data (ownership identifies the relationship between people and their information). A mechanism by which ownership can be asserted and protected. This is the most legally significant of all the OCAP principles. (Schnarch, 2004, quoted in Stout and Downey, 2006, p. 330)

In other words, the power transfer is real and could threaten existing power structures within organizations and society, including the policies and practices in question. Therefore, it becomes clear that essential factors in the definition of cultural safety are the visibility of cultural differences and the power that may flow from that visibility, leading to the demand for equality, respect and control by Aboriginal people.

In a tribute to the originator of the concept of cultural safety, Irihapeti Merenia Ramsden, Lis Ellison-Loschmann underlines the fact that cultural safety was a ‘big picture’ concept, encompassing broad political issues which could seem threatening to wider society:

[Ramsden] was an expert at seeing the ‘big picture’. She linked cultural safety with wider aspirations and contexts common to indigenous people, including notions of citizenship and sovereignty issues. Her later work developed these ideas further in recognizing and drawing on the commonality between the experience of colonization amongst indigenous peoples and the resultant cultural poverty and very real economic poverty which she was witnessing both here [New Zealand] and overseas.

A few of her other contemporaries also recognized the potential legacy of cultural safety early on. Irihapeti’s long time friend, lawyer and expert in the area of legal work on Maori rights, Moana Jackson, said in his interview with her: “Its [cultural safety] broadest strength, I think … is that it is a political idea and in the end remedying the ills of our people is a political and a constitutional issue, not in terms of … Parliament, but in terms of changing the mindset of our people about our power and our powerlessness …” (Ellison- Loschmann, 2003, p. 1).

In this way, the concept of cultural safety becomes a challenge to the power establishment in wider society, defined

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not just as a measure of the effectiveness of policy and delivery, but as a very real part of a political power struggle for control over one’s own life. Cultural safety becomes a means of changing broad attitudes and deep-seated conceptions, on an individual and community-wide basis.

However, the danger of broadening the definition of cultural safety too widely is that it loses its significance and practical relevance in specific policy areas. Politicizing the relationship between service providers and service recipients is of considerable theoretical interest, particularly in the ‘big picture’, but may be of limited practical value to either. The problem is two-fold: first, the power relationship is inherently unbalanced, where the qualified healthcare professional retains the power of their professional knowledge and practical capabilities of their position in relation to the relatively less powerful position of the patient; and second, a paradigm shift with a transfer of power may be of less practical value to a patient than a culturally knowledgeable, respectful and sensitive service provider. Literature sources based on practice (including handbooks, field experiments in healthcare delivery and first-hand reports on service delivery) return to the view of cultural safety as a further step on a continuum of cultural understanding, not because of any perception of the political threat of a paradigm shift, but because of tangible practical outcomes. Locating cultural safety on the cultural continuum makes it more achievable, effectively defining it as a better form of cultural competence, building a stronger and more trusting mutual relationship between receiver and provider.

To understand this, we will examine some key policy areas, namely, health, education, and self-determination. First, however, we will briefly touch on the issue of the pre- eminent visibility of Aboriginal cultural in any consideration of cultural safety.

2. Multiculturalism and cultural blindness This section of the paper briefly examines the issue of the visibility of Aboriginal cultures. The Assembly of First Nations argues that, to preserve a culture (and in particular a language), it is necessary to make the culture highly visible to Aboriginal and non-Aboriginal people alike (AFN, 2007, p. 10; AFN, 2008, p. 2).

Canada’s “diversity model” (Smith, 2003, p. 109) is built on a historical legacy of immigration, largely one based on European cultures, which we recognize today as a defining characteristic of Canadians’ self-image and political culture. One of the enduring nation-building myths of Canada’s inception as a nation is its founding

value of tolerance and accommodation of different cultures, religions and languages. However, the experience of many immigrants to Canada belied this myth of Canadian nationhood and exposed the highly British-oriented bias of government policy and attitudes of the times. In addition, the paternalistic legislative and policy stance of government towards Aboriginal people deprived them of basic human rights as well as what later became known as inherent rights of the First peoples in the land. The assimilationist policies, notably the residential schools policy, not only irreparably damaged the cultural identity of First Nations children in the schools, but also left a legacy of individuals, families and communities in crisis.

In the 1960s, Canada redefined itself explicitly as a multicultural nation, reflecting the civil rights movements in the USA and the image of Canada promoted by the leadership of then Prime Minister Pierre Trudeau. This diversity model, which continues to this day, hinges on two seemingly contradictory principles that form the foundations of public policy regarding ethnicity:

• Universalism – implying a blindness to difference, this focuses on individual rights and freedoms.

• Multiculturalism – implying a positive recognition of difference, this focuses on a celebration of the many cultures and ethnic origins of many Canadians. (Stasiulis & Abu-Laban, 2004, p. 371)

Canada’s relationship with the Aboriginal population demonstrated some of this ambivalence with separate cultural and ethnic identities. In 1969, following consultation between the government of Canada and Aboriginal leaders in which issues of Aboriginals and treaty rights and the right to self-government were prominently discussed, the Trudeau government introduced a ‘white paper’ which advocated the elimination of separate legal status for First Nations in Canada. The white paper amounted to an all-inclusive assimilation program which, if implemented, would have repealed the Indian Act, transferred responsibility for Indian Affairs to the provinces, and terminated the rights of First Nations people under the treaties made with the Crown.

For Prime Minister Trudeau, the white paper promoted the view of First Nations as Canadians like all others, served by the same departments, programs and services available to other Canadians. In other words, government would be blind to cultural differences and Aboriginal traditions, knowledge and languages. In this context, cultural blindness was seen as a virtue, eliminating racism and discriminatory

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treatment and attitudes, and effectively treating First Nations as if they were just another ethnic group that made up the multicultural profile of the Canadian population.

This view of Aboriginal society within Canada was vehemently rejected by Aboriginal people. Led by, amongst others, Harold Cardinal (1969), a leading First Nations activist in his powerful book The Unjust Society, the response to the White Paper acted as a call-to-arms for First Nations people in Canada. The result was a complete policy reversal by the federal government and the establishment of joint meetings between Aboriginal people and the government to determine policies based on explicit recognition of the distinctive interests of Canada’s Aboriginal peoples.

Ultimately, both the concepts of multiculturalism and cultural blindness were entirely inadequate in responding to the demands for recognition by Aboriginal people in Canada. In her book on cultural safety in New Zealand, Wepa draws attention to the distinctions between biculturalism and multiculturalism. Equating indigenous colonized histories with those of other immigrant groups is dangerous and invalid, she states, and risks further marginalizing Indigenous people (Kirkham, 2006, p. 334). Ramsden expresses the same argument that Indigenous people must be seen not as one cultural or ethnic group amongst many, but an equal founding nation and therefore with a rightful claim to a pre-eminent status (Ramsden, 2004, p. 175).

Furthermore, multiculturalism pays scant attention to the historical path that has led to communities facing social, psychological and economic crisis as a result of colonization and discrimination, and to the government’s own responsibility. By generalizing Aboriginal culture into the wider cultural mix of the modern Canadian state, it diminishes it and marginalizes the specific self-deterministic claims of Aboriginal people.

The concept of cultural safety can be seen as the direct antithesis of the concepts of both multiculturalism and universalism. Multiculturalism considers all cultures in Canada as having an equal claim on government and societal attention, and universalism downplays differences between individuals and communities into a single citizenry and seeks common interests based on general human rights. In contrast, cultural safety requires the explicit and detailed recognition of the cultural identity of the Indigenous people and the historical legacy of power relations and repression.

The issues of race relations and racism in Canada challenge the dominant myths of national identity of a tolerant, welcoming place where everyone enjoys the same opportunities and treatment at the hands of the state. Scholars in both Canada and the United States have

explored such national myths and how they create deeply held assumptions in both White and non-White people which perpetuate patterns of advantage and disadvantage. American scholar Peggy McIntosh turns the race debate on its head by exploring what she calls ‘privilege systems,’ the “unearned overadvantage [of White people] as a function of unearned disadvantage [of non-White people]” (McIntosh, 1988, p.1). Instead of focusing on non-White people in a White-dominated society, McIntosh focuses on the privileges enjoyed, even unconsciously, by White people, describing White privilege as “an invisible weightless backpack of unearned assets” (ibid, p.1).

Interestingly, this approach turns the notion of racial visibility and invisibility on its head. McIntosh explains that she was “taught to see racism only as individual acts of meanness, not in invisible systems conferring dominance on my group” (ibid, p. 1). Multiculturalism can be seen, not as a ‘celebration of diversity’, but a means of making culture and race invisible, by blurring and ultimately ignoring important differences between people into a meaningless notion of diversity. Verma St. Denis, a Canadian scholar examining race and education, particularly as it pertains to Aboriginal students, argues that the danger of the ‘multi-culturalism myth’ is that it creates an ideology of ‘racelessness’, making race invisible when it should be acknowledged and understood, and reinforcing Whiteness as the standard of what is normal. With colleague, Carol Schick, St. Denis examines racial attitudes in education in the Canadian prairie provinces, observing that the invisibility of White privilege which is accepted sub-consciously as the norm has the effect of marginalizing Aboriginal people and other racial minorities, and causing the ‘inferiorization’ of Aboriginal people for their apparent failure to meet White measures of success and achievement (Schick & St. Denis, 2005; St. Denis, 2007).

York University scholar Susan Dion takes the same view of race relations in education as St. Denis, underlining the need for carefully designed curricula to trace the history of the ‘colonial encounter’ between Aboriginal and non- aboriginal people and understand 20th century issues in the light of this history. Dion, like both St. Denis and McIntosh, stresses that the ‘transformation’ of inter-racial relationships places an obligation on White people to confront and understand their own racial identity and the way their dominant White culture shapes all of society and the norms by which people live (Dion, 2007).

Dion, St. Denis and McIntosh all relate their studies of interracial relations primarily to the field of education and curriculum-design. The relationship between teacher and student carries similar professional power imbalance

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as that between a healthcare professional and patient. Although none refer explicitly to the concept of cultural safety, their work explicitly recognizes the power relations and dichotomy of privilege and disadvantage inherent in race relations. Most interestingly, in contrast to the cultural competence model of transcultural relationships, these scholars all point to the need for White people, and White professionals in particular, to understand themselves and their own race and culture, rather than learning about their clients’ races and cultures. This element of self-knowledge is integral to cultural safety and any possible redefinition of power relations.

3. Transculturalism and cultural safety Clear recognition of cultural differences between non- Aboriginal and Aboriginal peoples is not sufficient to address the issue of the levels of recognition, understanding and knowledge, and the political implications that follow. In much of the literature (particularly that focus on nursing), different terms are used, apparently interchangeably, to refer to cultural considerations, ranging from sensitivity, competence, transcultural nursing and more recently to cultural safety. In some writing, the definition of cultural safety risks being flattened into a general concept of cultural understanding. Yet, as we have already seen, the concept of power and the recognition of the complexities of race relations in society are inseparable from cultural safety and distinguish it from other forms of cultural understanding. Ramsden dedicates a full chapter of her doctoral thesis to a discussion of the differences between transcultural nursing and culturally safe nursing (Ramsden, 2002, pp. 109-121).

Transcultural nursing, expounded in the writing of Leininger (1991, 1998) is, according to Ramsden, based on the traditional western approach to health care, represented by the non-Aboriginal nurse. Transcultural nursing focuses on the knowledge and understanding of Aboriginal culture of the Canadian nurse; it therefore uses as its starting point the norms of the nurse and, in this sense, represents an approach based on cultural competence, rather than cultural safety. Transcultural nursing appears to fit the model of race relations criticized by St. Denis and McIntosh, where the White professional establishes the context in which the service encounter will take place. In transcultural nursing, the power to define the norm and the onus for action to understand and know about another culture fall to the nurse (Ramsden, 2002, pp. 112-114). Ramsden views transcultural nursing as part of the multicultural approach to ethnic and cultural diversity; she states that most nurses in New Zealand practice culturally competent nursing

naturally, seeing the Maori culture as equivalent to other cultures in a multicultural modern nation state (Ramsden, 2002, p. 116). However, as McIntosh argues, learning about one culture in isolation without examining one’s own, cannot advance transcultural relations (McIntosh, 1998). In McIntosh’s analysis, transcultural nursing renders White culture invisible, an apparently neutral norm which depicts the nursing encounter as a one-way transaction and not a relationship of equals.

Interestingly, the emphasis in transcultural nursing is on learning, knowledge and understanding in order to allow predictions of the health of individuals, groups and cultures (Leininger, 1991). This practice of training nurses in indigenous cultures became known as ethno nursing and is based on the notion that ethnicity is a central driver of culture. However, the norms, and the power to define the norms, remain those of the nurse, not the patient. The power relationship therefore remains one of dominance by non-Aboriginal service providers over Aboriginal patients. The ultimate success of the relationship is based on and measured by the cultural competence of the non-Aboriginal nurse.

Ramsden redefines the equation between nurse and patient to realign the power structure. She stresses that it is the nurse who is alien to the Aboriginal patient and the norms and the power to define the norms should be in the hands of the person served (Ramsden, 2002, p. 114). In addition, Ramsden rejects the specific emphasis on ethnicity, focusing rather on “human diversity” (Ramsden, 2002, p. 119), which could include wider elements of culture, including gender, income, education, personal and community history, and life chances.

Cultural safety also views the interaction between a non-Aboriginal nurse and an Aboriginal patient as a ‘negotiated and equal partnership’ (explored in Cooney, 1994; Coup, 1996), in which trust plays a central part in sharing information and in rebuilding the relationship on a different way. The nurse’s skill lies in enabling people to say how service can be adapted and to negotiate an agreed approach (Ramsden, 1997).

Crucially, the outcome of the culturally safe practice is a two-way relationship built on respect and a bicultural exchange which aims for equality and shared responsibility. In her research on Inuit indigenous knowledge, Ellen Bielawski underlines that the Inuit people interviewed as part of anthropological studies objected to being questioned and interviewed, not because they wanted to withhold information, but because they wanted an exchange of stories and information, where they could learn about the

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other people’s lives in the same way their own were being examined (Bielawski, 1991, p. 1). In other words, the Inuit people sought equality and mutual respect.

The Assembly of First Nations (AFN) echoes this depiction of cultural safety as a bi-cultural exchange in both directions. The AFN contributes to the distinction of cultural safety by asserting the equality of the provider of the service and the recipient:

The concept has evolved to define cultural competence to be inclusive of the skills, knowledge and attitudes of practitioners. But this doesn’t acknowledge the experience of the patient, so we choose to consider a broader interpretation of cultural safety, in which the interaction between, and experiences of both the patient and the practitioner are respected, and First Nations cultures are visible and have similar power as mainstream culture (AFN, 2008, p. 2).

Furthermore, the AFN underlines the fact that cultural safety can only be defined and determined to be a success by the service recipient of the service, underlining again the issues of power and control:

The person who receives the services defines whether it was culturally safe. This shifts the power from the provider to the person in need of the service. This is an intentional method to also understand the power imbalance that is inherent in health service delivery (AFN, 2008, p. 2).

From its inception, transcultural nursing was premised on the notion of multiculturalism. The multicultural composition of the United States and Canada make cultural training a central part of nursing:

Given the multicultural composition of the United States and the projected increase in the number of culturally diverse individuals and groups in the future, it is apparent that there is an increasing need for nurses to focus on the cultural beliefs and practices of clients (Andrews as cited in Cooney, 1994, p. 9).

Transcultural nursing is consistent with the national models of multiculturalism and diversity, the mix of racial, ethnic, cultural, and language groups within the modern North American nation state.

In contrast, writers on cultural safety reject the models of multiculturalism and diversity. As we have seen in the writings of St. Denis and McIntosh, these terms are part of

the Canadian sense of national identity, but in fact can be seen as reinforcing White cultural dominance and diluting all other cultures into a raceless ‘otherness’. Cultural safety operates explicitly on a bicultural model, in which there are two parts to the dynamic relationship (Kearns, quoted in Ramsden, 2002, p. 110). All the literature on cultural safety reviewed looked specifically at Indigenous people, which underlines that biculturalism in this context applies not to any two cultures that may be at play in a social or professional interaction, but to the biculturalism of the dominant culture and the indigenous culture.

The significance of this debate between transcultural approaches to nursing and culturally safe nursing practice lies in the danger of redefining cultural safety away from structural and multifaceted social and political inequality to a more culturally descriptive approach. The writings of many politically-conscious commentators (Ramsden, 2002; Stout & Downey, 2006; Cooney, 1994) return to the political underpinnings of cultural safety to ensure that the term does not drift into the analytical framework of transcultural and ethno-nursing. In their definition, cultural safety is not built on knowledge and understanding of the indigenous culture, nor even on sensitivity to it. They insist on the political implications of self-determination and equality that form the foundations of cultural safety.

Cultural sensitivity and Transcultural Nursing are both concerned with having knowledge about ethnic diversity. This seems to be the basis of misinterpretation of the concept of Cultural Safety. The term ‘culture’ is read as ‘ethnicity’. But the skill for nurses does not lie in knowing the customs or even the health related beliefs of ethno-specific groups. The step before that lies in the professional acquisition of trust (Ramsden, 2002, p. 118).

Cultural safety has been described as superior to transcultural nursing because it does not require or expect nurses to become knowledgeable about other cultures but rather to understand and respect that other cultures have different ways of seeing things and doing things. The power is not on the nurse to decide what the individual should or must do (Coup, 1996, quoted in Ramsden, 2002, p. 118).

The emphasis on training in cultural safety is focused specifically on the history of Indigenous people who have suffered from colonization, with lasting effects on their well-being. Therefore, cultural safety pedagogy would focus on history, and the political, social and economic conditions, and environment of Indigenous people. Scholar Susan Dion describes this learning process as ‘remembrance’ and stresses that both Aboriginal and non-Aboriginal people in Canada

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have been shaped by the colonial experience (Dion, 2007). Ultimately, the deficiency of cultural competence is

that it is, as both a concept and as a practice, too one-sided and focuses on the knowledge and training of the service provider. This focus reinforces inherent power positions and reduces the role of Aboriginal patients to one of passive receivers of culturally competent behaviours. This is not to say that cultural competence does not play a crucial part in a successful interaction, but it cannot on its own create an equal relationship.

The transformation of the relationship cannot be effected through more culture training and greater knowledge by the service provider. The literature reinforces that a shift in the power positions needs to take place to build a strong relationship based on genuine respect, inclusive decision-making and joint effort. Such a culturally safe approach depends on the capacity, confidence and knowledge of both parties. Rather than viewing cultural safety as a mere shift of power, it can be viewed as mutual empowerment, where Aboriginal communities and individuals at risk or in crisis take an equal part in the solutions. The most constructive outcome of culturally safe Aboriginal and non-Aboriginal engagements are healthy and productive communities and individuals. Both parties require the capacity to play their part in successful engagements; this capacity depends on the knowledge, understanding and confidence of both, as well as their self- knowledge and cultural self-awareness.

This could be threatening to both Aboriginal and non- Aboriginal parties and carries risk for both. Power brings both opportunity and cost, and the added power accorded by a culturally safe approach to policy-delivery imposes responsibilities on Aboriginal institutions, governance structures and individuals. As stated at the outset of this paper, cultural safety can be taught and learned. Both parties in the cross-cultural engagements require the building blocks to manage and deploy the power of their position. These building blocks enable the parties to ‘navigate’ the engagement, allowing both parties to build the capacity not only to engage in an equal relationship, but to meet their goals. Where Ramsden and Ball saw cultural safety as an outcome in itself, the navigator models (see Goodman, 2006) use the process of culturally safe cross-cultural engagement as a means of achieving the real goals – the health and well-being of individuals and communities.

Ultimately, the goal of both the Aboriginal and non- Aboriginal members of the relationship is to work together to effect change for individuals and communities at risk or in crisis. At the individual, institutional and government levels, the parties need to view cultural safety as neither an

extension to cultural competence on the cultural continuum, nor as a paradigm shift, but as a navigation model to transform cross-cultural relationships.

4. Social determinants of health The context into which cultural safety must be applied is complex and varied, and the profound issues that accompany health concerns place additional pressure on government and social services to improve health outcomes for Aboriginal people. The environment in which people live has a profound effect on their health difficulties. These are known as the social determinants of health (SDOH), including poverty, unemployment, poor education, bad nutrition, poor housing, and unclean water. There is a huge and rich body of literature in this field, some of which has been collected and coordinated by the Commission on Social Determinants of Health, set up by the World Health Organization (WHO) in 2005 to promote health equity through a global movement. In its Final Report “Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health,” the Commission stated that:

Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death. Within countries there are dramatic differences in health that are closely linked with degrees of social disadvantage. Differences of this magnitude, within and between countries, simply should never happen (WHO, 2008).

In the context of SDOH, we can determine that there are three vantage points that must be considered as part of cultural safety: the past, the present and the future. For cultural safety to be achieved, all three viewpoints must form part of the understanding in bicultural exchanges. The past refers to the history of colonization and past injustices (again reflecting Dion’s reference to the need for ‘remembrance’). The present refers to the current lifestyle and living conditions that determine health. And the future refers to the aspirations and life chances of the people, as the people look to their future and for improvements in health, education and opportunity. In the study of Aboriginal women’s experiences with health care provision in British Columbia, Browne, Fiske and Thomas (2000) interviewed many First Nations women. One of the interviewees talked about the non-Aboriginal doctor’s attitude to her return to school:

He was proud, he was happy, I was going to school, I

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was doing well. I talked about my goals and things like this to him and he, he encouraged me. He encouraged me and he said that there’s nothing holding me back and I can be better than he is. And that’s what I liked (quoted in Browne, Fiske & Thomas, 2000, p. 24). Even a brief consideration of SDOH points to the

potentially wide application of the concept of cultural safety to many areas of Aboriginal policy which influence health outcomes. The focus of the literature that explicitly explores cultural safety is limited to a narrow area of healthcare delivery, specifically nursing. But to limit the discussion to nursing and health care delivery ignores the many issues, such as education, economic opportunity, and lifestyle issues (such as nutrition, smoking, and alcohol and drug consumption) that are integral to the area of health care delivery.

Although the academic and professional literature concentrates almost exclusively on a narrow range of health care delivery, it is clear that cultural safety must extend beyond health if its full implications are to be realized. If, as we have explored, cultural safety is concerned with relationships, trust, and respect in order to improve social outcomes, its relevance to a multitude of policy areas and social services is self-evident.

The issues raised under the banner of SDOH are of critical concern to communities at risk or in crisis. Projects to deal with health or other social problems in isolation of the context and environment in which many Aboriginal people live are unlikely to achieve lasting change. Aboriginal healing is concerned with holistic well-being, which supports programs that address specific problems, such as drug and alcohol addiction. Healing is an approach to SDOH that looks at the wider context, including the legacy of historical trauma, to find lasting solutions. Since many healing projects involve cross-cultural service encounters, cultural safety must be part of the healing process. Ultimately, it can be seen from practical experience that, to achieve optimal outcomes, cultural safety and cultural competence are both simultaneously necessary to the relationship: awareness and knowledge of Aboriginal culture and history, cultural self-knowledge by service provider, and a mutual and respectful relationship that focuses not only on specific service delivery but also on the aspirations and broader well-being of the client. Cultural competence and cultural safety are not mutually exclusive and may be the optimal combination to affect social improvement.

Through community healing, Aboriginal communities are able to effect preventative and remedial programming, drawing on the strengths of Aboriginal knowledge, culture and traditions (such as inter-generational support

and learning) within the community. From outside the community, Aboriginal people are empowered to demand culturally safe and culturally competent engagements with professional service providers to support and enhance community healing initiatives.

In order to explore the full meaning of cultural safety and its possible application to different areas of social policy, we now analyze a number of specific policy areas which make up the context and environment for Aboriginal health and wellness.

APPLICATION TO POLICY AREAS

Although the literature on cultural safety does represent an academic analysis, the ultimate aim of the concept is intensely practical. Many of the studies on health care delivery for Indigenous people in Canada, United States, New Zealand, Australia, and other countries are interested in cultural issues only as a means of improving program effectiveness and health outcomes. In this section, we examine some areas of public policy where the literature on cultural safety examines the relevance of the concept to produce these practical outcomes: health and the social determinants of health; education; and self-determination. In addition, in a subsequent section, the relevance of cultural safety is considered in the context of the criminal justice system.

Until now, much of the discussion on cultural safety has focused on individual health care professionals; in other words, we consider the power relations between two individuals – the nurse and the patient – when we consider cultural implications. However, key to this section is the recognition that it is institutions – government departments, hospitals, clinics, schools, etc. – that must demonstrate cultural safety and cultural competence in order to effect cultural change in the design and delivery of policy. This implies that the culturally safe behaviour and knowledge and the power transfer must be institutionalized. The impact of a single good doctor or nurse who builds respect, equality and trust into the relationship is not enough if the underlying policies and structures are culturally unsafe. The National Center for Cultural Competence (NCCC) defines culturally competent organizations as demonstrating:

• Set of values, principles & structures to work cross-

culturally. • Work in the cultural contexts of communities they

serve. • Work part of policy-making, administration,

practice and service delivery.

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• Systematically involve clients, families and communities.

• Cultural competence is a long-term developmental process.

• Both individuals and organizations are at various levels of awareness, knowledge and skills along the cultural competence continuum. (NCCC, retrieved Nov. 2008)

In the following areas of public policy, the issues of institutional cultural competence and structural power play pivotal roles in determining social policy outcomes.

1. Health To understand health as a policy area, it is necessary to consider the wider definition employed by the World Health Organization (WHO) and further supported by the WHO’s Commission on Social Determinants of Health (SDOH). WHO reports that the most common definition of health for the last fifty years is “a complete state of physical, mental and social well-being and not merely the absence of disease or infirmity” (Ustun & Jakob, 2005, quoted in Stout, 2008, p. 3). In this definition, the term ‘social well-being’ potentially includes a vast number of issues as social determinants of health, including a healthy cultural identity based on family and community life. As we have stated, a history of colonization, paternalistic policy-making, and residential schools actively destroyed or undermined the cultural identity of Aboriginal people in Canada.

Throughout the literature on cultural safety, the concern focuses on the failure of health policies and institutions to produce positive outcomes for Aboriginal people. As individuals and as communities, many Aboriginal people in Canada suffer from health and safety risks that appear as catastrophic failures within a wealthy, modern society.

Health issues are inherently part of the wider social and cultural context of Aboriginal life. The National Aboriginal Health Organization (NAHO) lists the broader determinants of health as:

• Access – hospitals, clinics, technology, healthcare practitioners being available within the community.

• Colonization – the legacy of poor health choices, and social dependency.

• Cultural continuity – the cultural foundation of traditional knowledge and cultural practices in the community to sustain healthy lifestyles.

• Globalization. • Migration – relocation of communities to make

way for logging, mining or hydro-electric damming.

• Poverty – unemployment and poor quality of life. • Self-determination – Aboriginal people taking

control over their own decisions as individuals and communities.

• Territory – the loss of traditional territory and occupations on the land, including the capacity to sustain a community through agriculture, fishing and hunting. (NAHO, 2007, p.11)

The National Conference on Social Determinants of Health brought together public health scholars and practitioners, and lists the following as the SDOH:

• Aboriginal status. • Early life. • Education. • Employment and working conditions. • Food security. • Gender. • Health care services. • Housing. • Income and its distribution. • Social safety net. • Social exclusion. • Unemployment and employment security.

(National Conference SDOH, 2002)

These again reflect the wider context of social, cultural and economic factors that influence health care provision and outcomes for Aboriginal people.

Constitutionally, health policies fall under provincial jurisdiction and the federal government has not, for the most part, accepted legal or fiduciary responsibility for the health care of Aboriginal people. However, in practice, Health Canada delivers major programs in Aboriginal health, focusing on community health, environmental health, non-insured health benefits, alcohol and drug rehabilitation, hospital services and capital construction.

Figures reported by Statistics Canada in 2002 show that some aspects of First Nations health are improving, such as longer life expectancies and reduced mortality rates (quoted in Government of Canada, 2004, pp. 228-220). At the same time, there are many other areas of concern, such as:

• Life expectancy remains lower than that of the Canadian population.

• Combined, circulatory diseases and injury account for nearly half of all mortality among First Nations people.

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20 Journal de la santé autochtone, novembre 2009

• Suicide and self-injury were the leading causes of death for youth and young adults, higher than the comparable Canadian population.

• Motor vehicle collisions were a leading cause of death for all Aboriginal age groups.

• First Nations have a rate of tuberculosis six times higher than the Canadian population.

• Rates of diabetes are increasing. • The smoking rate has increased, well over the

Canadian population. (Health Canada, 2000, 2008)

These health problems are symptomatic of underlying social, economic and political conditions that determine the health and life expectancy of Aboriginal people. Many Canadian studies have focused on income as a determinant of health, and a more recent trend in Canada, the United Kingdom and other European countries has been to view health outcomes as a result of people experiencing systematic material, social, cultural, and political exclusion from mainstream society. The inequalities of health have their roots in other societal inequalities reinforcing the political implications of health as a public policy issue.

A Health Canada report detailing plans for 2007-2008 (Health Canada, 2007) demonstrates the wide variety of initiatives and continuing programs designed to address the government’s major issues of concern and the resources dedicated to addressing them. However, despite significant improvements in health in general (including First Nations, Inuit, Métis, and urban Aboriginal groups), significant health inequalities in Canada persist, most notably among Aboriginal peoples (Raphael, 2004a, p. 8). Medicare means that lack of access to medical care cannot account for the inequalities. Similarly, the evidence over many decades shows that differences in health behaviours (such as tobacco and alcohol consumption, physical activity and diet) do not explain the disparities. Raphael and others determine that the inequalities in health can be explained in the different environments and conditions of life experienced by different groups in Canada. Income is a SDOH in itself, but it also gives an indication of other factors, including early life experiences, education, food security, employment, and working conditions.

The cost to be paid for culturally unsafe practices in terms of good health outcomes and social inclusiveness demonstrate that the status quo is not a satisfactory option. As Raphael notes, medical services that evoke these responses below are clearly of no use to individuals or the community. They include:

• Low utilization of available services. • Denial of suggestions that there is a problem. • Non-compliance with referrals or prescribed

interventions. • Reticence in interactions with practitioners. • Anger. • Low self-worth. • Complaints about lack of ‘cultural appropriateness’

of tools and interventions. (Raphael, 2004a)

Part of the difficulty of making lasting significant changes to the environment in which Aboriginal people live and the consequences they suffer lies in the approach taken by government to the governance of Aboriginal people. The paternalistic neo-colonial approach to Aboriginal affairs, both in legislation and public administration, is summed up in the continuing attitudes promoted in the Indian Act. The Act appears to violate the tenets of cultural safety, in that it perpetuates the institutionalization of outdated power structures, paternalistic policy-making and imposed western norms for Aboriginal self-determination.

Health policy regarding Aboriginal people which reflects the prescription of cultural safety could provide the policies to improve health outcomes, the institutional structures for on-going partnership and shared responsibility, and the symbolism of enlightened governance. In 2002, the Royal Commission on the future of health care in Canada published its report and dedicated a chapter to address specifically the health issues of Aboriginal people. The Report gathered considerable evidence of the gap between Aboriginal health indicators and Canadian society in general, including such issues as diabetes, HIV infection, cardiac problems, and high rates of disability, especially mental disability (Government of Canada, 2004, p. 219). The submissions of many Aboriginal people and organizations made clear that the route to improved health outcomes lay in greater involvement and control of health care policy and services of Aboriginal people and in broader inclusion of and respect for traditional approaches to healing. The Commission reflected this in its call for more partnership programs and ventures between government, institutions and Aboriginal communities (Government of Canada, 2004, pp. 219-220).

As noted by Stout and Downey (2006), changes in the institutions of governance and policy-making carry significant political implications. Political and institutional recognition that colonization, historical trauma, dislocation and loss of territory carry lasting health effects, carry

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political weight and financial cost. Prime Minister Stephen Harper’s apology to Aboriginal people for the residential schools program was the public culmination of many years of political and social struggle by Aboriginal people for recognition of past injustices. The most positive outcome of such recognition is the acceptance of partnership as a means of sharing power, responsibility and outcomes.

The partnership model is very complex within the context of the number of First Nations, with different governance models (for example, self-government agreements, Government of Nunavut and Land Claim Agreements), and within a federal national structure (jurisdictions of the federal government for Aboriginal affairs, and of the provincial government for health and social policy). In addition, a partnership approach can exist not just at the government or institutional level, but importantly also at the individual level. As Browne, Fiske and Thomas (2001) uncover in their study of health care for First Nations women in BC, individual doctors and nurses can achieve excellent relations with Aboriginal patients through practising an individual form of partnership, through sharing, trust and respect.

However, for communities at risk and in crisis, individual initiatives are not enough. Institutional partnership necessarily implies greater power in the hands of Aboriginal institutions, with complex negotiated power-sharing arrangements with different levels of government and institutions. Different First Nations have different health care priorities and partnership capacity, requiring potentially different power-sharing arrangements. Furthermore, government has an obligation to ensure accountability and transparency. As the negotiations between First Nations and the federal government on self- government demonstrated, a single model of power-sharing imposed on all the parties is unrealistic and does not account for the many different aspirations of First Nations.

As the Romanow Report underlined, partnership cannot function in an environment of competing jurisdictional claims (NAHO, 2001; First Nations Chiefs Health Committee, 2000, quoted in Government of Canada, 2004, p. 221). Different models for shared responsibility have been proposed, including (1) the status quo, where Health Canada enters into agreements with individual First Nations for delivery of health and social services; (2) health service delivery linked to an expanded First Nations self-government model; and (3) transfer of First Nations health issues to provincial jurisdiction. In its submission to the Romanow inquiry, NAHO called for a multi-jurisdictional approach to health service reform (NAHO, 2001, quoted in Author, 2002, p. 224).

Any bi-jurisdictional or multi-jurisdictional partnership on primary health care must have as its foundation equal involvement of First Nations. The cultural safety model requires that the power-sharing be genuine, be based not just on western institutions and concepts, including jurisdiction, constitutionality, and the court system. In addition, it must be based on genuine respect for traditional approaches to decision-making, holistic healing and community-building.

Historians of the evolution of public health talk about two revolutions in public health improvements: the first was the control of infectious diseases, and the second the battle against non-communicable diseases. Romanow calls these two revolutions ‘illness models’ and calls upon government and civil society to bring about a third revolution which he refers to as a ‘wellness’ model. The wellness model moves from a consideration of illness towards illness prevention and a holistic sense of well-being. To bring this about, Raphael talks in terms which invoke the thinking behind cultural safety. The wellness model requires:

• Inspired leaders genuinely committed to share power with those less fortunate.

• A commitment to social inclusion and Civil Society that provides opportunities for all Canadians to participate in the things that count in our neighbourhoods across this great country.

• An understanding that hopelessness kills and hopefulness with opportunity is a prescription for good health. (Romanow, in Raphael, 2004, p. ix)

Most tellingly, Romanow talks about sharing power as a determinant of health and well-being. This recalls the work of Ramsden, Cooney and others on the pivotal role of power in cultural safety. Similarly, the sense of hopefulness and opportunity underpin the notions of aspiration and looking to the future that emerge from the literature on cultural safety. Romanow’s vision fits well within the cultural safety model.

2. Education Health care dominates the literature on cultural safety virtually to the exclusion of all other social issues. However, as we saw in the discussion of the social determinants of health, it is impossible to separate health care from the wider social context. Possibly the single most important social issue for inclusion within the cultural safety model is education, particularly at the secondary and post-secondary levels. There is a vast body of literature on education policy

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and Aboriginal people, but very little that explicitly links it with the concept of cultural safety.

Issues surrounding the residential schools program put primary and secondary education squarely in the discussion on cultural safety, as the source of cultural destructiveness and anomie. Like other Aboriginal policies, education has been governed by federal and provincial government policies that were paternalistic, imposed and assimilationist. Within the context of education policy, the term ‘anomie’ has particular resonance, particularly in light of the history of residential schools. The term, developed by French sociologist, Emile Durkheim in 1893, describes a state in which there is a breakdown of the norms that guide individual and group social behaviour. A norm is a socially enforced rule or custom of behaviour which shapes individuals’ expectations of how they should behave and how others will behave towards them. Norms are created and passed on through family and community life, cultural ceremony, rituals, stories, and religions.

Furthermore, Durkheim extended the use of the term anomie as part of functionalist theory. Functionalism focuses on the structure and workings of society, and views society as a series of interdependent parts – family, education, religion, law and order, media – which act as an organic whole. Later he expanded the concept to include psychological anomie, where individuals lose their personal moral regulation, leading potentially to depression and suicide. There is both personal anxiety and a disruption in the rhythm of social life, as economic status and family anomie increase in the face of normlessness and powerlessness (Greene, 2003, p. A-22).

Educational institutions, curricula and styles of learning are part of the structural functionalist model that produces economic prosperity, social stability and individual and community well-being. If individuals are removed from their family and cultural home, the cultural anomie they experience cuts them off from the norms of their society, leaving a legacy of personal and community damage.

As part of the healing process, education at secondary and post-secondary levels in particular plays a crucial part of building strong Aboriginal communities. Stable, resilient communities need capable, confident human resources to become community leaders, skilled workers and good parents. However, despite the great emphasis in Canadian culture on the value of education, modern western education fails many Aboriginal youth. Under the Indian Act, the federal government provides educational services to First Nations students from ages 6 to 18 that are living on reserve. In fact, while most on-reserve elementary schools are federally funded, provincial governments maintain jurisdiction over secondary education.

Despite progress reported in education achievement of Aboriginal students over the past forty years, disparities in educational achievement between Aboriginal and non- Aboriginal youth persist. Scholars Paul Maxim and Jerry White studied students across Canada and found that, compared with non-Aboriginal youths, young Aboriginal people aged 18-20 are much more likely to be without a high school diploma (42.5 per cent versus 23.5 per cent) and much less likely to be in post-secondary education (35.5 per cent versus 53.9 per cent). The lower rate of high school completion also widens the gap between Aboriginal and non-Aboriginal economic and social prospects (Maxim & White, 2006, p. 34) International comparisons show these disparities even more starkly: Canada currently ranks among the top five on the United Nations’ Human Development Index, which measures economic growth with the capabilities of the country’s population. Canada’s Aboriginal population ranks 78th (Kloster, 2008).

Cultural safety addresses these issues of cultural anomie and powerlessness. The central tenets of cultural safety as applied to education would require: (1) Aboriginal people exercising control over the education of their children and youth, possibly through partnerships with educationalists and institutions; and (2) recognition of and respect for traditional education and indigenous knowledge.

Aboriginal people have asserted their own aspirations for community-based education. In the report of the Royal Commission on Aboriginal peoples (RCAP) (1996), the Commission recommended that Aboriginal people should have a greater voice in determining the shape and content of the education of Aboriginal children and youth. The report based its recommendations on a vision of the relationship between non-Aboriginal Canadians and Aboriginal peoples, founded on the recognition of Aboriginal peoples as self- governing nations (Government of Canada, 1996). However, in reality, partnerships or shared power arrangements over education are, like the issue of health care, complicated by federal and provincial jurisdiction over the education of Aboriginal children and youth, and by the role of the institutions themselves. Cooperative ventures, such as Aboriginal-specific programs and services, special funding and Aboriginal involvement in curriculum design, have been successful at the post-secondary level in colleges and universities. These bicultural efforts at cultural safety in education have succeeded in helping Aboriginal students gain entry to and stay in mainstream post-secondary institutions. Examples include: the First Nations University, started in 1976 in partnership with the University of Regina is overseen by the Federation of Saskatchewan Indian Nations; the Gabriel Dumont Institute of Native

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Studies, also a partnership venture with the University of Regina. Also, the Province of British Columbia signed a memorandum of understanding (MOU) with the First Nations of B.C. regarding a new relationship to promote the education and advancement of First Nations people in B.C. The MOU is written in terms that are consistent with the principles of cultural safety, in terms of equal partnership, respect for First Nations languages and cultures, and Aboriginal control over program curricula and programs.

Traditional approaches to education are based on the hunter-gatherer life on the land, allowing people to gain sound knowledge and understanding about the environment and underlying ecological processes. This knowledge was passed down from generation to generation through various methods of traditional education. Through family and community, the Elders pass onto youth the norms, knowledge and moral values of the whole society. Traditional learning processes included ceremonies, rituals, imitation, demonstration, oral story-telling, and songs (Ulluwishewa, Kaloko & Morican, 1997, pp. 1-3).

The power relations addressed within the definition of cultural safety are applicable to the education relationship. As in the health field, within the concept of cultural safety, power is transferred to the person who receives the service, to judge whether the service was culturally safe. In the educational setting, cultural safety refers to the student’s feelings during the learning exchange, while the teacher must demonstrate cultural competence (in the sense of knowledge of the culture of the student) and cultural safety (in the sense of respect, trust and equality of the interaction) (NAHO, 2006a).

Culturally safe teaching practices have also been the subject of considerable study, though the actual term ‘cultural safety’ has not been transferred from the health literature. Scholar Pamela Toulouse draws on growing research when she argues that Aboriginal students’ self- esteem is a key factor in success in school. She lists a number of factors that contribute to the academic success of Aboriginal students:

• Educators who have high expectations and truly care for Aboriginal students.

• Classroom environments that honour who they are and where they come from.

• Teaching practices that reflect Aboriginal learning styles (differentiated instruction and evaluation).

• Schools with strong partnerships with Aboriginal communities. (Toulouse, 2008, pp. 1-2)

As in the health arena, the success of the bicultural

educational encounter between teacher and student must be a two-way exchange, based on an equal partnership. The teacher’s skills and knowledge must allow for the student to feel respected and understood. The student must feel safe in order to enter into their part of the encounter.

3. Self-determination As discussed in Part I of this paper, a key factor in the definition of cultural safety in much of the literature is the transfer of power from the service provider to the service recipient. Specifically, the literature talks about the power held by a Canadian doctor or nurse in relation to the Aboriginal patient, derived from their position of authority, education and professional knowledge, their questioning of the patient, and ultimately in their decision regarding treatment. However, as stated, there is little in the literature to explain this power transfer: what power does the Aboriginal patient have, particularly as all the sources of the health care professional’s power are still in place? What does the power transfer enable the Aboriginal patient to do?

To find some answers to these questions, it is necessary to look elsewhere in the literature on self-determination of Aboriginal peoples. The two phrases, ‘self-determination’ and ‘self-government’, are sometimes used interchangeably. We use the term ‘self-determination’ in this context, as it implies a broader range of arrangements where an individual or a community exercises control over their lives. While self- government conveys a generally similar meaning, it has been used to mean the negotiated transfer of certain powers of government to First Nations. While this is certainly relevant, self-government could be just one of several ways in which Aboriginal people exercise power.

In the body of literature on Aboriginal self-government, the concept of cultural safety does not appear. However, power plays an important part in the definition of cultural safety as defined by Ramsden, Cooney, Stout and Downey and others, and self-determination is about power. Used in the context of health care, the term ‘self-determination’ has both conceptual connotations for Aboriginal people of regaining a cultural identity damaged by colonization, and practical connotations of improving health outcomes through personal empowerment.

Simply put, self-determination is seen by Aboriginal people as a means of regaining control over the management of matters that directly affect them and preserve their cultural identities. Self-determination as a concept encompasses a variety of forms which allow Aboriginal people to regain control at some level. At the same time, it may be a matter of practicality for Aboriginal people to take

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advantage of those forms of self-determination which can be negotiated and agreed quickly. For this reason, in the field of health and education, partnerships with non-Aboriginal institutions, such as clinics, health and wellness programs, universities, and colleges, have achieved promising results in promoting health and learning.

Other forms of self-determination demonstrate the flexibility of the term, allowing actions which reclaim control or assert cultural identity to fall within its definition. These could include: a strong political voice through Aboriginal organizations; inspirational community leadership and role models; the reinterpretation of historical events; use of Aboriginal languages; the formation of inter- tribal and international networks; recognition and respect for traditional knowledge; the establishment of Aboriginal schools, colleges, community centres, clinics, treatment centres, and cultural and spiritual institutions; the use of cultural symbols and ceremony in the community and in wider Canadian society; a greater role for Elders; the use of consensual decision-making; the use of traditional healing and justice; and negotiated treaties and agreements granting greater governance powers to First Nations. Finally, the literature on cultural safety in health care implies that self-determination exists also in the form of individual confidence and self-esteem, personal choices about treatment, an equal exchange of information with health care professionals, and a feeling of trust.

The forms of self-determination adopted by each First Nation depend on the wishes and needs of the community and the issues they face. Indeed, as University of Victoria Indigenous advisor Roger John said as part of the University of Victoria course on cultural safety, indigenous communities struggle to decide the best way to take control:

Power to define, because that’s one of the first powers that’s taken away from us as Indigenous people, is that we’re no longer able to decide who is Indigenous and who is not … The power to define who we are, to decide who’s who, who’s a member of our community and who’s not. The power to protect our land, to protect ourselves, to protect our family … And then the power to decide is probably one of the areas we’re hurting the most in now, … we need to reclaim ourselves and there’s lots of struggle in our communities now about that power – who’s going to decide what we do and how we do it? (University of Victoria, accessed Nov. 2008).

As John suggests, communities must build collective, inclusive decision-making processes based on Aboriginal

principles to decide what is best for them. In terms of self-government, the options available

to First Nations are limited by constitutional and legal considerations and the willingness of the Canadian government and the courts to cede governance powers to First Nations. From 1995, self-government was the cornerstone of federal government Aboriginal policy in accordance with section 35 of the Constitution Act, 1982 (Inherent Right of Self-Government). At a Special Chiefs Assembly held in Vancouver in March 2005, First Nations Chiefs issued a news release stating that they were united in charting a path to self-government:

The plan calls for a formal political accord between First Nations and Canada, a joint framework for the recognition and implementation of First Nations government, and immediate initiatives to support First Nations consensus and necessary capacity development. The plan also calls for the elimination of the Department of Indian Affairs to be replaced by a new Ministry of First Nations-Crown Relations and an Aboriginal and Treaty Rights Tribunal (AFN, 2005).

With the hindsight of some years since these words were written, it is evident that self-government in the formal sense of negotiated agreements on the transferring of governance powers and funds to First Nations has been piecemeal and limited, with serious reservations on both sides of the negotiation.

Taiaiake Alfred, a Kanien’kehaka scholar and commentator on the effects of colonialism on Indigenous peoples, interprets the present situation in Canada as ‘two competing agendas’ at work. Alfred sees self-government as the way of assimilation, wrongly focusing on “money and jurisdiction. It is about the psychological effects of cultural destruction through colonialism.” Alfred observes that “big institutional solutions will not work … People are not prepared to handle self-government at this point. Self- government is not a form of government that is a reflection of their culture and their values. It is not authentic” (TVO, 2005). Alfred views self-government as an alien form of self-determination, defined and expressed in foreign terms and subject to foreign processes.

This points to the need for a more spiritual and traditional form of self-determination. The emphasis is not on power so much as on empowerment and Aboriginal people making their own decisions that directly affect them, using the language, values and processes of their culture. In fact, far from the formal negotiating tables of

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the self-government policy, many thousands of projects and programs have been spearheaded by Aboriginal communities to deal with specific issues of health, education or social programming.

The aspects of this form of self-determination, focusing on spirituality, tradition, respect, and community are in keeping with the concept of cultural safety. The cultural safety model of Aboriginal power does not advocate separateness of the Aboriginal community. Alfred expressed a vision in keeping with cultural safety, of a ‘respectful relationship between two nations’ (TVO, 2005). This is consistent with Ramsden’s conception of cultural safety as, by definition, bicultural (Ramsden, 2004; Coup, 1996), based on equality and respect. Ramsden did not conceive cultural safety with any separatist or independent political connotations; it was a way of defining a two-way relationship.

PERSONAL AND COMMUNITY HEALING

One of the basic premises of the power of self- determination for Aboriginal people is the capacity and skills of community leaders and members to exercise that power. As we saw when looking at education, First Nations are developing institutions and curricula to build the capacity in their youth. However, one of the legacies of colonialism is social and economic conditions that often preclude full participation in their community and wider society.

These conditions, which we touched on when considering the social determinants of health, put communities at risk and potentially in crisis unless healing can take place. In this section we look at the subject of healing from three perspectives: the concept of healing in general, community healing, and indigenous knowledge and law.

1. Healing The Aboriginal healing movement is based on a traditional community-based shared counselling process which includes physical, emotional, mental, and spiritual healing. It traditionally involves Elders bringing together the people involved in a dispute or harmful incident to talk, listen and learn from each other and to agree on a solution.

Healing can be visualized as part of the circle of life, of balance and harmony, as taught through the medicine wheel. The medicine wheel encapsulates the four components of the human experience which are referred to as states of being: spiritual, emotional, physical and mental. Through these states of being, people can achieve healing through a

balanced, holistic approach. While there are variations in the way First Nations depict the medicine wheel, generally the healing path of the medicine wheel includes a:

• Talking Lodge. • Listening and Teaching Lodge. • Healing Path Lodge. • Healing Lodge.

In practice, the healing movement has included various activities which can support Aboriginal peoples in coming to terms with wrongs and injustices. These have included participation in traditional healing and cultural activities, such as: culturally based wilderness camps, treatment and healing programs, counselling in groups, and community development projects. Healing can be at the level of the individual, the family or the community.

As part of the process of addressing past injustices, Aboriginal communities have implemented traditional healing methods. For example, the Aboriginal Healing Foundation was founded in 1998 to design, manage and implement a healing strategy for Métis, Inuit and First Nations people affected by the legacy of physical and sexual abuse suffered in residential schools. As part of the reconciliation process in June 2008, the Prime Minister apologized to residential school victims in the House of Commons. In addition some provincial governments have devised joint strategies to address issues of healing, such as the Ontario Aboriginal Healing and Wellness Strategy.

Healing can come in the form of the acknowledged truth of Aboriginal peoples’ suffering, including the Prime Minister’s official apology on behalf of all Canadians, and the establishment through partnership of the Truth and Reconciliation Commission (TRC) in 2008. The TRC was established through agreement by legal counsel for residential schools students, legal counsel for the churches, the Government of Canada, the Assembly of First Nations and other Aboriginal organizations. Its stated purpose is to inform:

…all Canadians about what happened in these schools so that the Commission can guide and inspire Aboriginal peoples – and all of Canada – in a process of truth and healing on a path leading towards reconciliation and renewed relationships based on mutual understanding and respect (TRC, 2008).

Healing is promoted by the TRC as a society-wide exercise, whereby Aboriginal and non-Aboriginal peoples come to terms with the past and redefine the future. In this

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way, the healing relationship is depicted in the same way as the cultural safety model and is consistent with the writings of St. Denis and McIntosh regarding the need for mutual understanding and also self-knowledge and understanding.

Healing also comes in the form of practical work and funding. In 1994, the Ontario Government and fifteen First Nations and Aboriginal organizations introduced the collaborative Aboriginal Healing and Wellness Strategy and renewed it in 2004. The strategy comprised two parts: the first focused on Aboriginal health, including giving Aboriginal people more control over planning and delivery of health care services to their communities; and the second focusing on family healing, dealing with issues of families at risk, including domestic violence and dysfunction (Ministry of Community and Social Services, 1994). Emerging from this strategy is a healing method that is consistent with the essential features of cultural safety: equality of First Nations people in a partnership, recognition and respect for Aboriginal culture, knowledge of Aboriginal culture, the implementation of traditional knowledge, and the self- determination of Aboriginal people. Aboriginal communities were able to channel funds in a variety of traditional and mainstream programs to help families, including support in situations of family violence, suicide prevention, community wellness programs, medical hostels, drug and alcohol treatment centres, and traditional healing lodges.

For example, the Odawa Native Friendship Centre (ONFC) in Ottawa runs a healing and wellness program focusing on the social impacts of colonization. Wellness focuses on the present, producing functional individuals, families, communities, and nations, and also on the future by encouraging aspirations in young Aboriginal people (ONFC, retrieved November 2008).

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