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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 signicant impact the way policy and services are
developed at an institutional level in elds 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, denes cultural safety and
how it diers 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 ve areas.
KEYWORDS
Colonization, cultural safety, healing and wellness, historical trauma, social determinants of
health
INTRODUCTION
6 Journal de la santé autochtone, novembre 2009
1. Introduction and denition
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.
e aim is to understand First Nations communities
at risk and in crisis and the eectiveness 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. e 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.
e concept of cultural safety evolved as Aboriginal
people and organizations adopted the term to dene new
approaches to healthcare and community healing. Much
of the literature conrms that a denition 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
Journal of Aboriginal Health, November 2009 7
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.
e 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 dened as “any actions that diminish, demean
or disempower the cultural identity and well-being of an
individual” (Cooney, 1994). As this denition 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 eld, but also other
areas of social policy.
However, the generality of this denition 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 dierence it makes
to policy development and delivery, and where cultural
safety lies conceptually and in practice in relation to previous
considerations of cultural dierence.
is paper seeks to clarify and deepen the denition 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 beneted 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. rough
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. e 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 oers 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 aects 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 eectiveness (Wesley-
Esquimaux, 2004). is 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 benets of
cultural safety is scarce. e most concentrated investigation
of the applicability of culturally safe practice is found in
literature from the New Zealand and Australian health care
eld, largely focused on nursing. Even here, the evidence
is largely qualitative and anecdotal. e 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. e 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.
is 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 dierent 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
Cultural Safety
8 Journal de la santé autochtone, novembre 2009
the power to dene the quality of healthcare to Aboriginal
patients according to their ethnic, cultural and individual
norms. us, cultural safety as a concept incorporates the idea
of a changed power structure that carries with it potentially
dicult social and political ramications (Ramsden, 2002;
Cooney, 1994). e introduction of the concept of cultural
safety to the debate on cross-cultural healthcare was
signicant: 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 benets 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. ere 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. e 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 dierent 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 sucient attention to communities at risk
or in crisis. erefore, 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. e 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 eective if it
does not acknowledge and take some account of the cultural
context in which it is applied. e idea that government
policy may fail or its eects be mitigated by cultural
misunderstandings or ignorance presents the imperative
behind the concept of the cultural safety.
2. Literature Search
e literature search includes academic literature, focused
both on health and indigenous cultures, grey literature and
the Internet. e timeframe for the search concentrates on
the past ten years, from the rst serious research on cultural
safety, and draws on signicant contributions to the canon
beyond fteen years. e 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. e 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 identied
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
e 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). ey identied primary research articles on health
Cultural Safety
Journal of Aboriginal Health, November 2009 9
outcomes and well-being found in Medline from January
1995 to March 2006. e study found that health outcomes
and patient satisfaction evidence were very promising but
in the early stages of development. ey 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). e
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 identied 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.
e 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 dierence cultural safety
brings to policy outcomes. Research on cultural safety is
an emerging eld; 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. ey form the
basis for eective 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.
is 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 eectiveness 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.
ese examples demonstrate part of the diculty
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. is 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 identied
cultural safety as critical to healing, and that relationships
based on acceptance, trust and safety are the rst step in the
healing process (AHF, 2003a, 2008). In her analysis of the
evidence, Marlene Brant Castellano found:
e 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).
is is consistent with the ndings 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 identied 156 papers of which none had evidence-
based research. In short, though there is signicant 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
denition 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
Cultural Safety
10 Journal de la santé autochtone, novembre 2009
communities’ development is focused on best practices,
lessons learned and innovation. ere 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. e 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, omas (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.
is 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
roughout the literature, there is considerable reference to
the concept and practice of cultural competence. is 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. us, cultural
competence and cultural safety are both represented as
points on a continuum of cultural approaches.
Elsewhere, the literature reveals a dierent
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. is conceptualization
of cultural safety represents a more radical, politicized
understanding of cultural consideration, eectively 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. e 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. is demonstrates
where cultural safety is situated in terms of negative
approaches ranging to the positive. is 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. e
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. is 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 nal outcome of this
learning process (NAHO, 2006b). In eect, 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
signicant addition of the role and consequent power of the
Aboriginal patient in the determination of the relationship.
e 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
Cultural Safety
Journal of Aboriginal Health, November 2009 11
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 redene cultural safety from a transformative
point of view of the Aboriginal person receiving care; the
determination of success is by the recipient, who denes the
care received as culturally safe, or not.
Ramsden eectively 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. is 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. ere are important dierences 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. e term implies the reversal of cultural
danger or peril, where individuals and communities may be
at risk or in crisis. e concept entails not just the agreement
and understanding that cultural dierences matter in social
and health policy delivery, but also the need to make a
real dierence in methods of delivery and the ultimate
eectiveness 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. us,
Ball eectively 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 ve 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. e steps on the linear
continuum or the concentric circles eectively depict the
responsibilities of the service provider in the relationship.
e conceptualization of cultural safety as a paradigm shift
Cultural Safety
12 Journal de la santé autochtone, novembre 2009
focuses on the role of the recipient, not as a passive receiver
of services, but a powerful player in a relationship. In
essence, the dierences 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. ey 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 specic 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 eect, 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’. ey 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 redenition of some conditions as diseases, including
historical trauma. e 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. e OCAP principles are built upon Aboriginal
claims for genuine self-determination. ey include:
• Ownership: a community or group owns
information collectively in the same way that an
individual owns his or her personal information.
• Control: arms 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. e right for Aboriginal communities to
manage and make decisions regarding access to
their information and resources.
• Possession: Actual physical control of data
(ownership identies the relationship between
people and their information). A mechanism by
which ownership can be asserted and protected.
is is the most legally signicant 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.
erefore, it becomes clear that essential factors in the
denition of cultural safety are the visibility of cultural
dierences and the power that may ow 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, dened
Cultural Safety
Journal of Aboriginal Health, November 2009 13
not just as a measure of the eectiveness 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 denition of
cultural safety too widely is that it loses its signicance and
practical relevance in specic 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.
e problem is two-fold: rst, the power relationship is
inherently unbalanced, where the qualied 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, eld experiments in healthcare delivery and
rst-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, eectively dening 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 briey touch on the issue of the pre-
eminent visibility of Aboriginal cultural in any consideration
of cultural safety.
2. Multiculturalism and cultural blindness
is section of the paper briey examines the issue of the
visibility of Aboriginal cultures. e 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 dening 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 dierent 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. e 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 redened itself explicitly as a
multicultural nation, reecting the civil rights movements
in the USA and the image of Canada promoted by the
leadership of then Prime Minister Pierre Trudeau. is
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 dierence,
this focuses on individual rights and freedoms.
• Multiculturalism – implying a positive recognition
of dierence, 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. e white paper
amounted to an all-inclusive assimilation program which,
if implemented, would have repealed the Indian Act,
transferred responsibility for Indian Aairs 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 dierences and Aboriginal traditions,
knowledge and languages. In this context, cultural blindness
was seen as a virtue, eliminating racism and discriminatory
Cultural Safety
14 Journal de la santé autochtone, novembre 2009
treatment and attitudes, and eectively treating First
Nations as if they were just another ethnic group that made
up the multicultural prole of the Canadian population.
is 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 e Unjust Society, the response
to the White Paper acted as a call-to-arms for First Nations
people in Canada. e 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 specic self-deterministic
claims of Aboriginal people.
e 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 dierences
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.
e 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
dierences 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 eect 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 eld of education
and curriculum-design. e relationship between teacher
and student carries similar professional power imbalance
Cultural Safety
Journal of Aboriginal Health, November 2009 15
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. is element of self-knowledge
is integral to cultural safety and any possible redenition of
power relations.
3. Transculturalism and cultural safety
Clear recognition of cultural dierences between non-
Aboriginal and Aboriginal peoples is not sucient 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),
dierent 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 denition of cultural
safety risks being attened 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 dierences 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 t 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 dene 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). is 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 dene
the norms, remain those of the nurse, not the patient. e
power relationship therefore remains one of dominance by
non-Aboriginal service providers over Aboriginal patients.
e ultimate success of the relationship is based on and
measured by the cultural competence of the non-Aboriginal
nurse.
Ramsden redenes 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 dene the norms should be in
the hands of the person served (Ramsden, 2002, p. 114).
In addition, Ramsden rejects the specic 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 dierent way. e 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
Cultural Safety
16 Journal de la santé autochtone, novembre 2009
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.
e Assembly of First Nations (AFN) echoes this
depiction of cultural safety as a bi-cultural exchange in
both directions. e AFN contributes to the distinction of
cultural safety by asserting the equality of the provider of the
service and the recipient:
e concept has evolved to dene 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 dened and determined to be a success
by the service recipient of the service, underlining again the
issues of power and control:
e person who receives the services denes whether
it was culturally safe. is shifts the power from the
provider to the person in need of the service. is 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. e 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 specically 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.
e signicance of this debate between transcultural
approaches to nursing and culturally safe nursing practice
lies in the danger of redening cultural safety away from
structural and multifaceted social and political inequality to
a more culturally descriptive approach. e 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 denition, cultural safety is not built
on knowledge and understanding of the indigenous culture,
nor even on sensitivity to it. ey 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. is seems to be the basis of misinterpretation
of the concept of Cultural Safety. e 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-specic groups. e 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
dierent ways of seeing things and doing things. e power
is not on the nurse to decide what the individual should or
must do (Coup, 1996, quoted in Ramsden, 2002, p. 118).
e emphasis on training in cultural safety is focused
specically on the history of Indigenous people who have
suered from colonization, with lasting eects on their
well-being. erefore, 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
Cultural Safety
Journal of Aboriginal Health, November 2009 17
have been shaped by the colonial experience (Dion, 2007).
Ultimately, the deciency 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. is focus reinforces inherent power positions and
reduces the role of Aboriginal patients to one of passive
receivers of culturally competent behaviours. is 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.
e transformation of the relationship cannot
be eected through more culture training and greater
knowledge by the service provider. e 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 eort. Such a culturally
safe approach depends on the capacity, condence 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. e 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 condence of both, as well as their self-
knowledge and cultural self-awareness.
is 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.
ese 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 eect 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
e 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. e environment in which people live has a profound
eect on their health diculties. ese are known as the
social determinants of health (SDOH), including poverty,
unemployment, poor education, bad nutrition, poor
housing, and unclean water. ere is a huge and rich body
of literature in this eld, 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 aects
the way people live, their consequent chance of illness,
and their risk of premature death. Within countries
there are dramatic dierences in health that are closely
linked with degrees of social disadvantage. Dierences
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.
e past refers to the history of colonization and past
injustices (again reecting Dion’s reference to the need for
‘remembrance’). e 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 omas (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
Cultural Safety
18 Journal de la santé autochtone, novembre 2009
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 & omas, 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 inuence health
outcomes. e focus of the literature that explicitly explores
cultural safety is limited to a narrow area of healthcare
delivery, specically 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.
e 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 specic 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 nd 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 specic 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 aect social improvement.
rough community healing, Aboriginal communities
are able to eect 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 dierent areas of social policy,
we now analyze a number of specic 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
eectiveness 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 eect
cultural change in the design and delivery of policy. is
implies that the culturally safe behaviour and knowledge and
the power transfer must be institutionalized. e 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. e National
Center for Cultural Competence (NCCC) denes 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.
Cultural Safety
Journal of Aboriginal Health, November 2009 19
• 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 denition 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 denition of health
for the last fty years is “a complete state of physical, mental
and social well-being and not merely the absence of disease
or inrmity” (Ustun & Jakob, 2005, quoted in Stout, 2008, p.
3). In this denition, 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.
roughout 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 suer 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. e 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, shing
and hunting. (NAHO, 2007, p.11)
e 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)
ese again reect the wider context of social, cultural
and economic factors that inuence 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 duciary 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 benets, 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.
Cultural Safety
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.
• e smoking rate has increased, well over the
Canadian population. (Health Canada, 2000, 2008)
ese 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. e 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 signicant
improvements in health in general (including First Nations,
Inuit, Métis, and urban Aboriginal groups), signicant
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 dierences 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 dierent
environments and conditions of life experienced by dierent
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.
e 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. ey 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 diculty of making lasting signicant
changes to the environment in which Aboriginal people live
and the consequences they suer lies in the approach taken
by government to the governance of Aboriginal people. e
paternalistic neo-colonial approach to Aboriginal aairs,
both in legislation and public administration, is summed up
in the continuing attitudes promoted in the Indian Act. e
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
reects 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 specically the health issues of Aboriginal people.
e 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). e
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. e
Commission reected 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
signicant political implications. Political and institutional
recognition that colonization, historical trauma, dislocation
and loss of territory carry lasting health eects, carry
Cultural Safety
Journal of Aboriginal Health, November 2009 21
political weight and nancial 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. e most positive outcome of
such recognition is the acceptance of partnership as a means
of sharing power, responsibility and outcomes.
e partnership model is very complex within the
context of the number of First Nations, with dierent
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
aairs, 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 omas (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 dierent levels of
government and institutions. Dierent First Nations have
dierent health care priorities and partnership capacity,
requiring potentially dierent 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 dierent 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). Dierent 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. e 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 rst 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. e 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. e 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. is 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 ts 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. ere is a vast body of literature on education policy
Cultural Safety
22 Journal de la santé autochtone, novembre 2009
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. e 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. ere 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 o 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, condent 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). e 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 ve 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. e 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. e 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-specic programs and services, special funding
and Aboriginal involvement in curriculum design, have
been successful at the post-secondary level in colleges and
universities. ese bicultural eorts 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
Cultural Safety
Journal of Aboriginal Health, November 2009 23
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.
e 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. is knowledge
was passed down from generation to generation through
various methods of traditional education. rough 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).
e power relations addressed within the denition of
cultural safety are applicable to the education relationship.
As in the health eld, 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 reect Aboriginal learning
styles (dierentiated 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. e
teacher’s skills and knowledge must allow for the student to
feel respected and understood. e 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
denition of cultural safety in much of the literature is the
transfer of power from the service provider to the service
recipient. Specically, 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 nd some answers to these questions, it is necessary
to look elsewhere in the literature on self-determination of
Aboriginal peoples. e 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 denition of cultural
safety as dened 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 aect 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
Cultural Safety
24 Journal de la santé autochtone, novembre 2009
advantage of those forms of self-determination which can
be negotiated and agreed quickly. For this reason, in the eld
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
exibility of the term, allowing actions which reclaim
control or assert cultural identity to fall within its denition.
ese 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
condence and self-esteem, personal choices about
treatment, an equal exchange of information with health
care professionals, and a feeling of trust.
e 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 dene, because that’s one of the rst 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 … e power to dene who we are, to
decide who’s who, who’s a member of our community
and who’s not. e 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:
e 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. e plan also calls for the elimination of
the Department of Indian Aairs 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 eects 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 eects 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 reection
of their culture and their values. It is not authentic” (TVO,
2005). Alfred views self-government as an alien form of
self-determination, dened and expressed in foreign terms
and subject to foreign processes.
is points to the need for a more spiritual and
traditional form of self-determination. e emphasis is not
on power so much as on empowerment and Aboriginal
people making their own decisions that directly aect
them, using the language, values and processes of their
culture. In fact, far from the formal negotiating tables of
Cultural Safety
Journal of Aboriginal Health, November 2009 25
the self-government policy, many thousands of projects
and programs have been spearheaded by Aboriginal
communities to deal with specic issues of health, education
or social programming.
e aspects of this form of self-determination, focusing
on spirituality, tradition, respect, and community are in
keeping with the concept of cultural safety. e 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). is is consistent with
Ramsden’s conception of cultural safety as, by denition,
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 dening 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.
ese 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
e 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.
e medicine wheel encapsulates the four components of
the human experience which are referred to as states of
being: spiritual, emotional, physical and mental. rough
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. ese 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 aected by the legacy of physical and
sexual abuse suered 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’ suering, including the Prime
Minister’s ocial apology on behalf of all Canadians, and
the establishment through partnership of the Truth and
Reconciliation Commission (TRC) in 2008. e 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 redene the future. In this
Cultural Safety
26 Journal de la santé autochtone, novembre 2009
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 fteen
First Nations and Aboriginal organizations introduced the
collaborative Aboriginal Healing and Wellness Strategy
and renewed it in 2004. e strategy comprised two parts:
the rst 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).
2. Community healing
e literature on cultural safety is curiously silent on
the issue of communities in crisis. e cultural safety of
nurses’ interaction with Aboriginal patients is dened
in individual terms, with the feelings of the individual
patient determining the success of the interaction. But the
application of cultural safety to the wellness of a community
is not considered.
In “E-nakaskakowaaahk=A Step Back,” Canadian
scholar Peter Kulchyski (2004) describes the three informal
questions he asks when getting a sense of the overall well-
being of an Aboriginal community:
1. Culture – are the children playing and laughing in
their own Aboriginal languages?
2. Respect for Elders – are there Elders in the
community who are being treated with respect?
3. Health and safety of the people – can I drink the
water? (Kulchyski, 2004, p. 1)
Kulchyski underlines that the use of Aboriginal
languages and the central role of Elders goes beyond the
ceremonial, and is the link to the cultural wealth of the
community in terms of traditional knowledge and history.
rough the Elders, the community has access to the
traditional symbols and practices of healing that foster
cultural identity. Kulchyski’s criteria underline both culture
and the material living conditions under which people live.
However, Aboriginal communities face dierent
challenges depending on their history and resources. It is
possible to imagine other questions that could be asked in
dierent circumstances, such as questions about the state
of housing, the existence of employment opportunities, and
the condition of the family. In the literature on Aboriginal
communities and economic development are descriptions
of communities who have healed from crisis to create a
vibrant healthy life for their residents. In reviewing some
communities that are on the healing path, the example of
the Oujé Bougoumou Crees shows how cultural safety
could be applied to community healing. e community
was relocated seven times in 50 years to make way for
mining operations. Finally, in 1990, in a settlement with
the governments of Quebec and of Canada, the community
was recognized as a band and received money and land to
build their community. Oujé-Bougoumou constructed their
community to showcase their spiritual renewal, building
traditional symbols of healing into their physical structures.
An aerial view of the community shows the healing circle,
with open, modern architecture in its public buildings. From
“the very beginning, our objective has been to build a place
and an environment that produces healthy, secure, condent
and optimistic people” (Bosum, retrieved November 2008).
Cultural symbols are an important part of the healing
process, reecting cultural identity in the design of their
living space. Cultural symbols also play a part in the body of
wisdom and knowledge built over generations.
3. Indigenous knowledge and law
Indigenous knowledge is “a complete knowledge system
with its own epistemology, philosophy and scientic and
logical validity…which can only be understood by means of
pedagogy traditionally employed by the people themselves”
(Battiste & Henderson, 2000, p. 41).
Knowledge is the condition of knowing something
with familiarity gained through experience or association.
e traditional knowledge of Aboriginal peoples has roots
based rmly in the Canadian landscape and a land-based
Cultural Safety
Journal of Aboriginal Health, November 2009 27
life experience gained over thousands of years. Traditional
knowledge oers a view of the world, aspirations, and a way
to dene certain life truths, dierent from those held by
non-Aboriginal people whose knowledge is based largely on
European philosophies (Bilawski, 1991, p. 11). In Nunavut,
the Inuit traditional knowledge, expressed in the Inuit
Qaujimajatuqangit (IQ), forms a guiding set of values for
the whole territorial government (Pauktuutit, 2006, p.6).
Indigenous knowledge is passed from generation to
generation, by word of mouth, ceremonies and teachings,
and has been the basis for agriculture, food preparation,
health care, education, conservation, and the wide range of
other activities that sustain a society and its environment in
many parts of the world for many centuries.
Much of indigenous knowledge stems from the broad
understanding of the ecosystems in which Indigenous
people live and ways of using natural resources in a
sustainable manner. However, colonial education systems
replaced the practical everyday life aspects of indigenous
knowledge and ways of knowing with western notions of
abstract knowledge and academic ways of learning. Part
of cultural safety includes the eorts by Aboriginal people
in Canada to preserve their traditional knowledge and
to teach it to their children. Similarly, the responsibility
on Canadian service deliverers is to give due respect and
place to indigenous knowledge in many areas of life,
including health, education, family relations, healing, justice,
community life, and governance.
Indigenous knowledge is subject to considerable
misunderstanding and stereotyping by Canadian society.
… today as in the past they are prey to stereotyping
by the outside world. By some they are idealized as
the embodiment of spiritual values; by others they
are denigrated as an obstacle to economic progress.
However, they are neither: they are people who cherish
their own distinct cultures, are the victims of past and
present-day colonialism, and are determined to survive
(Strong, 1990, p. 6).
Indigenous knowledge allows Aboriginal people to
express themselves in languages and terms which reinforce
their social, spiritual, political, and cultural identity. While
indigenous knowledge can be of practical use to individuals
and families, in the context of cultural safety, its signicance
is in the recognition of and respect shown by service
providers for traditional ways of doing things.
Indigenous knowledge also encompasses traditional
laws. For many years, the legal systems of Canada’s
Aboriginal people were ignored or dismissed because they
were inconsistent with western laws and legal jurisprudence.
Aboriginal customary laws, like Aboriginal stories, history
and songs, were not written down, and Aboriginal societies
generally did not accord a single person or group with
the authority to dene and enforce the laws. erefore,
following colonization, in a western tradition of written
laws, legal jurisprudence and formal court structures,
Aboriginal customary laws had no place (Pauktuutit, 2006,
p. 9). However, strains and problems on the criminal justice
system have encouraged policy-makers and judges to look
more closely at Aboriginal law in relation to Aboriginal
oenders.
Canada has long relied heavily on incarceration; while
this is a problem for the population in general, it is of
particular concern to the Aboriginal people, both urban
and rural, living on- and o-reserve. Aboriginal people are
disproportionately over-represented in Canadian prisons
(Haslip, 2000, p. 3). To address this issue and to consider
Aboriginal culture and indigenous knowledge as part
of a possible solution, in 1996, the federal government
announced the Aboriginal Justice Strategy and amended
the sentencing provisions of the Criminal Code to meet the
needs of Aboriginal oenders. Over many years, the social,
economic and political dislocation of Aboriginal people
through colonization led to conditions of life that result in
a higher incidence of crime among Aboriginal peoples and
alienation from the criminal justice system. e Supreme
Court, while acknowledging that not all Aboriginal
communities have the same conception of sentencing and
justice, gave the view that: “most traditional Aboriginal
conceptions of sentencing place a primary emphasis
upon the ideals of restorative justice” (LaPrairie, 1990, p.
726, quoted in Haslip, 2000, p. 4) and that “the dierent
conceptions of sentencing held by many Aboriginal People
share a common underlying principle … the importance
of community sanctions” (LaPrairie, 1990, p. 727, quoted
in Haslip, 2000, p. 4). In the context of inter-dependent
members of a community living in a sometimes harsh
environment, restoration of stability and the preservation
of the community were of paramount importance in the
traditional justice system.
Indigenous knowledge and laws strengthen Aboriginal
people in claiming the respect and equality in relation to
gures of authority in Canadian society, including nurses,
teachers, social workers, judges, and others. e strength
of the community and its stability are fundamental to
Aboriginal people; social cohesion has been the key to
survival for many Indigenous people, both physically and
culturally (Strong, 1990).
It is evident that Aboriginal people can draw on
the strength of their indigenous knowledge and cultures.
Cultural Safety
28 Journal de la santé autochtone, novembre 2009
However, as Ramsden insists, the cultural safety model is
about the combination of two cultures, interacting in the
course of everyday life in a multitude of ways. In this sense,
there is the opportunity for enrichment for non-Aboriginal
society as well in terms of mutual respect and understanding.
In the Truth and Reconciliation Report, Anne Salmond
comments: “...the process of opening Western knowledge
to traditional rationalities has hardly yet begun” (Bielawski,
2004, p. 1).
CONCLUSION
e concept of cultural safety has extended beyond its
origins in the literature concerning nursing in New
Zealand. It resonates with Indigenous peoples around
the world, and has been explored in academic literature,
government reports and professional studies in relation
to the health of Indigenous people, particularly in New
Zealand, Australia and Canada. Similarly, it relates
usefully to other subjects where Indigenous people are
disproportionately disadvantaged in social policy areas, such
as education, economic opportunity and criminal justice.
However, it remains conned largely to academic studies
and government reports, and little hard evidence appears to
have been applied to professional practice. It seems that the
practicalities of cultural safety as an outcome rather than a
concept have yet to be realized.
is is in part due to the lack of evidence based on
extensive eld research. e vast majority of the literature
remains qualitative and anecdotal. e qualitative data needs
to be substantiated in quantitative studies that can provide
comparative data over time and cross-sectional data. is
data would allow government and practitioners to assess the
usefulness of cultural safety as a part of professional practice
by non-Aboriginal service providers (whether health care
professionals, teachers, social workers, judges or lawyers) in
relation to their Aboriginal clients. Such quantitative studies
require lengthy timespans to produce meaningful data. ese
may be underway, but as yet such evidence is not available.
From an Aboriginal perspective the evidence for cultural
safety is imbedded in traditional knowledge, teachings and
values of Elders and healers.
Furthermore, as several writers have discussed, the
concept of cultural safety carries an explicit political
component. is derives from the express transfer of power
in a culturally safe exchange from the professional to the
Aboriginal client, where the success of the exchange is
judged by the Aboriginal person, and not the professional.
Expressing cultural safety in terms of power explicitly
challenges the existing power structures within institutions
and wider society and can appear threatening. e
professional literature (that is, literature from medical and
nursing documents that are written by and for practicing
professionals) suggests that, even when forcefully promoting
Aboriginal interests, the term cultural safety is often avoided
in favour of cultural competence or transcultural practice. As
explored in the paper, while these alternative terms express
a genuine desire to improve service delivery and service
eectiveness to Aboriginal people, they stress a dierent
angle on the non-Aboriginal professional - Aboriginal client
relationship. In some cases, the term cultural safety appears
to be used interchangeably with cultural competence,
diluting the signicance of the concept of cultural safety as
it originated in New Zealand nursing literature.
e long-term value of the concept of cultural safety
as a tool for cultural regeneration is hard to assess and
depends on the integrity of the processes that underlie the
concept of cultural safety. In New Zealand, when the term
was rst being debated in civil society and government,
there was a suggestion that the term ‘cultural safety’ could be
changed to be less politically challenging without diluting
its signicance and reach. is was rejected by many Maori
observers who felt that cultural safety is and must be seen as
a challenge, to eect real change in the delivery of medical
and government services.
e dierences between the concept of cultural safety
versus cultural competence and transcultural practice
are profound, but they could be used to imply dierent
angles of the same exchange. Cultural competence and
transcultural practice, like cultural safety, are both based
on an assumption of respect for Aboriginal people, their
culture and knowledge, and the building of trust between
the professional and the client. Cultural competence and
transcultural practice are both dened in terms of the non-
Aboriginal professional’s knowledge and understanding of
the culture of their Aboriginal client.
Cultural competence (and the linked concepts of
cultural sensitivity and transcultural practice) is based on the
process of building an eective service delivery interaction
with Aboriginal clients, rather than the outcome of the
success of the interaction. However knowledgeable or
sensitive the professional is, this does not in itself ensure the
eectiveness of the interaction.
e concepts of cultural competence and transcultural
practice measure success in terms of the knowledge of
professionals; therefore, recommendations for achieving
cultural competence contained in the literature commonly
feature extensive culture training for professionals
(nurses). Proponents of the concept of cultural safety (see
Ramsden, Coup, Cooney, and Ball, ) regard this as useful
Cultural Safety
Journal of Aboriginal Health, November 2009 29
but inadequate. While it is desirable that professionals
be knowledgeable of Aboriginal cultures, this criterion is
inadequate to ensure that the outcome of the interaction with
Aboriginal clients is culturally safe. For Ramsden, Cooney
and Coup, the approach taken in cultural competence falls
far short because it leaves the power of the interaction in the
hands of the professional. For these writers, knowledge of
Aboriginal cultures may be helpful, but it is not necessary
for culturally safe interaction to take place. It can be
extrapolated from their writing that a professional without
in-depth knowledge of Aboriginal culture can still perform
their work in a culturally safe manner.
Cultural safety relies rather on the expectation on
the parts of the non-Aboriginal professional and the
Aboriginal client that it is the client who has the power to
make decisions regarding their health (or other matters)
and also the power to judge if the interaction has been
culturally safe. Unlike training to acquire knowledge of
Aboriginal culture, training under cultural safety focuses on
the nature of cultural safety itself (respect, trust, sharing)
and on the history of Aboriginal people that contributes to
the contemporary conditions of many Aboriginal People
(colonization, residential schools, etc.).
Some of the diculties of implementing culturally safe
practice can be discerned in the brief analysis of specic areas
of policy in the paper. Health is an area of social policy that
lends itself particularly well to the practice of cultural safety.
Non-Aboriginal doctors and nurses, with the education and
professional qualications in western science and medicine,
with the condence and certainties of their culture, have
considerable power. Studies (see Browne, Fiske and omas)
show how individual health professionals have considerable
impact when they show the respect and attitudes that could
be described as culturally safe. Respect for the Aboriginal
patient extends beyond the individual to their culture, to
the teachings of their traditional knowledge, practices and
spirituality and to their aspirations for the future.
However, for cultural safety to become entrenched
in professional practice in health and other policy areas,
including education at all levels, justice, and social work,
cultural safety has to be practiced not just by individuals
but also by institutions. Pamela Toulouse’s writing about
promoting education for Aboriginal children, spoke not just
of teachers and their direct relationship with Aboriginal
students, but also of the curricula, the teaching and learning
styles, Aboriginal content in lessons, language and even the
physical design of schools. For example, she asserts that even
a welcome sign over the door in the Aboriginal language
of the Aboriginal students can create a respectful and
encouraging sense of belonging (Toulouse, 2008). Similar
examples of cultural safety can be found in the case studies
in the appendices of this paper.
Professionals may display culturally safe behaviour
and language in the execution of their job individually, but
for signicant changes to take place in Canadian society,
institutions and government must display culturally safe
attitudes and put in place training that ensures consistency in
service delivery. In literature on the nature of discrimination
and alienation (see Haslip, 2000), it is evident that the
most dicult type of discrimination to address is systemic
discrimination. Systemic discrimination is discrimination
embedded in policies and practices that appear neutral on
the surface and implemented impartially by practitioners.
However they have a disproportionately adverse
aect on specic groups of people. is is evident in the
literature on the experiences of Aboriginal people in the
criminal justice system, the secondary and post-secondary
education system, the health system, and in other areas of
social determinants of health (such as housing, employment,
nutrition, poverty, etc., see Raphael, 2004). is suggests
that systemic discrimination or lack of eective outcomes
stem from institutional and governmental failure in relation
to cultural safety. Finally, cultural safety begs the question
of what power means and how it can be exercised. e
literature on cultural safety does not explore how power
can support Aboriginal people in their interactions with
non-Aboriginal service deliverers. However, looking at
the literature on self-determination, we nd many ways in
which Aboriginal people gain greater control over matters
that aect them, many of which are much less complex
and easier to implement than self-government. Academic
thinking on issues of Aboriginal power considers how
individuals, families and communities gain power by simply
engaging in struggles or actions; winning or losing can be
less important than the action of standing up for one’s beliefs
and interests (Kulchyski, 2005).
is power applies not just to Aboriginal individuals in
a private interaction with a professional person, but also to
families and communities. Kulchyski (2005) explores this in
the concept of community wellness. He sees empowerment
as a source of community and family pride through
engaging in struggles and taking steps to improve lives
and promote healing. He relates empowerment explicitly
to the strengths of Aboriginal communities: Aboriginal
language, culture, ceremonies, traditional knowledge, and
spirituality. Although this is not explicitly related to the
concept of cultural safety, it is useful as it leads to the
issue of communities at risk and communities in crisis.
Since the literature on cultural safety focuses strongly on
the individual level of Aboriginal people interacting with
Cultural Safety
30 Journal de la santé autochtone, novembre 2009
health care professionals, it is largely silent on the issues of
community wellness and communities at risk and in crisis.
First Nations Elders and practitioners see cultural safety as
a means to strengthen individual, family and community
resilience to respond to crisis and community stress. In this
sense communities see cultural safety as that rst step along
the healing path. However, moving from the issue of power
to culture, it is possible to see links that could be explored in
literature in the future.
RECOMMENDATIONS
Recommendations include the following:
Training:
1. Training for professionals who deliver services
directly to Aboriginal people in Aboriginal cultural
(to achieve cultural competence).
2. Training for professionals in the history of the
Aboriginal community they are interacting with (to
start the process of achieving cultural safety).
3. Training for professionals and institutional
administrators in the concept and practice of
cultural safety.
4. Support for cultural safety educators to have a
dialogue on a regular basis and create a body of
teaching materials.
5. Professional competencies to include cultural safety
for all service deliverers, not just those who have
regular contact with an Aboriginal client-base.
6. Role models and case studies in terms of culturally
safe practice to be put in place within institutions
to promote cultural safety best practices in an
applied context.
7. A training manual or guide to be developed that
incorporates the concepts of cultural safety, cultural
competency and healing to provide Aboriginal
communities with a step-by-step how to manual on
cultural safety.
8. A training manual to be developed to support
organizations in developing their own training and
policies on cultural safety.
9. Community leaders to be trained in cultural safety,
to build in the symbols of empowerment that
could establish community pride and renewal. In
conjunction with other initiatives, cultural safety
could be promoted as renewed power and social
standing of Aboriginal culture.
Qualications and reward:
1. Professional qualications to require an
understanding of culturally safe practice.
2. Reward strategies to be developed to reect a
‘cultural safety’ competency.
Research:
1. Support and participation in studies on cultural
safety by Aboriginal institutions and First Nations
communities, possibly in partnership with academic
institutions or professional institutions.
2. Lobby through Aboriginal institutions and leaders
for government support for research into cultural
safety and the possible applications in public policy
and organizational policy.
3. Build a body of data on the experiences of
Aboriginal service recipients on cultural safety
to reinforce good practice and training (through
interviews, questionnaires and studies).
Strategies:
1. Cultural safety and healing strategies should be
included in First Nations community initiatives,
programs and policies dealing with the stressors
that push them from risk to crisis.
2. First Nations students should be recruited to post-
secondary programs to assume healthcare jobs and
other positions of authority.
3. Aboriginal leaders and communities should be
involved in establishing standards and policies
on cultural safety, through partnership in health,
education and other elds.
Education:
1. First Nations to work with post-secondary
institutions to ensure that support programs are
culturally appropriate and to support training of
teachers and administrators in cultural safety.
2. Post-secondary institutions to build strong
relationships with local First Nations to foster links
and gain new Aboriginal entrants. (Brascoupé,
2008)
Cultural Safety
Journal of Aboriginal Health, November 2009 31
APPENDIX A - Tsow Tun Le Lum Society
Case Study
Substance Abuse Treatment Centre
Tsow-Tun Le Lum means “helping house,” providing
addiction and substance abuse programs in an accredited
treatment centre in Lantzville, on Vancouver Island, British
Columbia. It also supports the survivors of trauma and
residential schools. Its mission is to strengthen the ability of
First Nations people to live healthy, happy lives and to have
pride in their native identity.
In the rst phase of the Tsow-Tun Le Lum program,
participants learn about:
• Trust building and safety of the individual.
• Physical, emotional and sexual abuse.
• Eects of unresolved trauma and cultural
oppression.
• Consequences of shame.
e Tsow-Tun Le Lum Centre like other Aboriginal
Healing Foundation projects have learned that building
safety and trust is a critical rst step because clients have
lost the sense of safety because of trauma and eects of
residential school. e following information was collected
at the Aboriginal Healing Foundation’s Projects Gathering
“Safety” workshop on April 22, 2008 in Saskatoon,
Saskatchewan.
What is safety?
Safety for the Aboriginal Healing Foundation’s (AHF)
projects can be dened as both personal safety and cultural
safety, alluding to the identity of every person as an
individual and as a member of a cultural community. e
rst step in the healing process is to establish safety and
trust with clients. Safety can restore power and control to
survivors and foster responsibility for self and a feeling of
belonging.
Safety for Aboriginal Healing Foundation
Projects (Simon Brascoupé, 2008)
Personal Safety: What do we mean by personal safety for
survivors, workers and in centres?
Building trust:
Build foundation with clients to start intensive
treatment.
Dependability, consistency.
Ensure condentiality:
Condentiality and privacy policies clear at all levels of
contact (personal and professional).
Client rights:
Rights clearly stated; code of ethics, guiding principles,
etc.
Communicate centre’s principles, e.g., posters in healing
centres.
Advocate for client’s rights.
Group/team rules or self-directed guidelines created by
clients.
Safe therapeutic process:
Intake, triage area or buer zone for evaluation of
needs.
Explain and introduce the process clearly to clients.
Orientation process and package for clients.
Explain and dene worker/client boundaries.
Explain plan or road map for healing journey.
Clients develop and maintain self-care plan and/or a
wellness plan.
Let clients know they have freedom of choice with
options.
Empower clients.
Appropriate:
Sincere, non-judgemental, trustworthy.
Walk the talk; be visible and involved in the community.
Love oneself and have humility.
Have good intentions about what you do as a service
provider.
Respect choices, cultural diversity in community and
other people’s ways.
Don’t impose beliefs onto others.
Have a mentor to turn to for support.
Practice self-care techniques.
Ensure workers are healthy mentors.
Safe hiring; reference, security checks, etc.
Create safe atmosphere:
Warm, respectful, welcoming environments.
Be available, consistent, open and unbiased.
Create an environment where clients don’t feel
Cultural Safety
32 Journal de la santé autochtone, novembre 2009
shame, e.g., especially if they don’t have knowledge or
experience.
Respect is key (signage that encourages respect).
Listen and learn.
Be accepting, empathic and don’t criticize.
Be non-judgemental, patient and respectful.
Use humour.
Create comfortable place:
Building should be warm and welcoming.
Orientation of building and grounds.
Create space for healing.
Naming, i.e., name of facility should be meaningful
culturally.
Reinforce safety:
rough proper closure, follow-up and aftercare.
Survivors need to know that assistance is available
throughout their healing journey.
Cultural Safety: What does cultural safety mean for
survivors, workers and centres?
Elders:
Elders’ participation is key. Know who providers are, i.e.,
Elders who have walked the talk.
Cultural activities:
Explain and introduce process, i.e., reconnect to culture.
Follow cultural protocols.
Utilize local cultural resources.
Traditional ceremonial practices.
Augment with western, alternative and other practices.
Encourage participation in the cultural program and
activities.
Feasts, i.e., appropriate behaviour/protocols for Elders’
feasts.
Freedom to choose to participate.
Respect all cultures – be appropriate for audience and
not exclusionary, e.g., smudge, sweet grass, eagle feather.
Understand family unit and structure and respect
relationships, i.e., what does it mean to be father/
mother/grandfather/son/aunt etc.
Encourage parents to educate their children.
Understand who we are as First Nations people, e.g.,
do not let diversity become a barrier, such as religious
denominations.
Cultural competency training:
Ensure sta understands the diversity of the
community.
Become familiar with cultural and other ways, e.g., not
only one way.
Being a First Nations person is a way of life.
Provide cross-cultural workshops.
Provide education and awareness about cultural
teachings and traditional ceremonies.
Provide appropriate teaching and encouragement.
Understand ceremonies and protocols, e.g.,
similarities/dierence between churches and First
Nations.
Retain, speak and learn traditional languages.
Physical environment reinforces cultural identity:
Gardens, healing ponds, sweat lodges, etc.
Healing room for ceremonies and resource.
Utilize cultural symbols, e.g., bualo hides, elk horns,
eagle feathers, dream catchers.
Lessons Learned
Creating safety and trust is a critical rst step for First
Nations individuals and communities. e Aboriginal
Healing Foundation projects have demonstrated this
approach to safety which includes both personal and
cultural safety, such as in the case of the Tsow-Tun Le
Lum Treatment Centre.
Policy Implications
Strategies for communities in crisis and at risk
should include safety in the development, design and
implementation.
Rationale
If in fact safety is a critical rst step, and without it the
development of safety and trust, the eectiveness of a
project, relationship or strategy is endangered – policy,
programs and plans for communities at risk and in crisis
should have a carefully crafted approach to safety at
all levels of development, design and implementation.
is could be incorporated in capacity development
(community development), participatory approaches, again
at all levels and include use of traditional knowledge.
Project implementation
e AHF and this case study clearly demonstrates how
successful projects incorporate safety at all levels of delivery
and show policies makers how to design projects that meet
the needs of communities at risk and in crisis.
Cultural Safety
Journal of Aboriginal Health, November 2009 33
Safe Trusting Relations
When working with First Nations communities building
trust can be critical to program or project success,
particularly with communities at risk and communities
in crisis. ese communities’ dysfunctions stem from
colonization caused by historical trauma and residential
school. e rst step in the healing process is to establish
safety and trust. Safety can restore power and control to
survivors and foster responsibility for self and a feeling
of belonging. So it is critical that the government team
and individuals working with communities at risk and in
crisis develop safe and trusting relations with First Nations
communities. Developing safe and trusting relationships can
be accomplished through cultural competency training and
an institutional cultural competency policy. (AHF, 2008)
APPENDIX B - Hollow Water First Nation
Case Study
Community Holistic Circle Healing (CHCH), Manitoba
Hollow Water First Nation is one hundred fty miles
northeast of Winnipeg. In 1984 a healing and development
team was formed to work in Hollow Water and the Métis
settlements of Manigotogan, Aghaming and Seymourville.
e team was comprised of political leaders, service
providers from all health and service agencies. e team’s
objective was to create a safe and healthy community
for their children and grandchildren by achieving two
objectives: 1. to facilitate individual and community healing
journeys; and 2. to coordinate integrated program services,
such as education, politics, health, religion, and economy.
Safe and Healthy Community
Hollow Water was a community in crisis; it had a history
of violence, suicide, addiction problems and sexual
abuse. Community Holistic Circle Healing made a
remarkable transformation through community healing
and restorative justice. Hollow Water clearly demonstrates
that a community-based approach founded on traditional
knowledge can successfully deal with historical trauma and
residential schools painful past. In 1988 they established a
program called S.A.F.E.:
What followed was a very active period of learning
and healing. e Resource Group consulted with
many groups across North America who was dealing
with similar issues and by 1988 had set up their own
training program called S.A.F.E. (Self-Awareness For
Everyone), modeled after the New Directions Training
being oered at that time by the community of Alkali
Lake. is step allowed them to bring this type of
training to as many of their community members who
were willing to begin a journey of personal healing and
development (Bushie, n.d.).
e team found that building of trust and
communication contributed to a dramatic increase in
disclosures. e team would gently record the victim’s story;
they ensured the victim’s safety; and with the presence of
trusted people oered support to the victim through the
crisis. Healing at Hollow Water occurred at the community,
family and individual level.
e Healing Journey is shown in the medicine wheel,
as a four step process that in the experience of Hollow
Water took three to ve years. In the end, it resulted in
restitution and reconciliation between the abuser and the
victim, the victim’s family and the whole community. Every
journey begins with the talking circle where all sides are
heard – individuals speak from the heart. It is here at the
talking stage that personal and cultural safety is critical to
getting the process started. Many believe that colonization
has resulted in mistrust of authority by First Nations
communities which is a barrier to be overcome in every
process and relationship. Whether it’s hearing their anger,
stories and pain or silence – building trust through safe
practice is a huge challenge. e second step is learning,
the circle shares what it has learned from each other in the
talking circle. e third step is the healing journey where
there is consensus on the path to follow. Finally, the results
are transformation, restoration and reconciliation.
Medicine Wheel: e Healing Journey
(Brascoupé, 2008)
Hollow Water has achieved remarkable results through its
CHCH approach. e team identied further work needed
to link their work to other issues and priorities.
1. Healing Lodge: build a healing lodge that can
serve as a centre for both residential and outreach
programs with the capacity to take in whole
families.
2. Cultural Foundations of Treatment: to blend it
with Hollow Waters traditional healing approach
the healing practiced by dominant culture
professional psychologists.
3. Linking Treatment to Training: link treatment to
training, which transforms healing to social and
economic well-being of the community.
Cultural Safety
34 Journal de la santé autochtone, novembre 2009
4. e Key Role of Women: women have led the
healing movement in Anishnaabe communities.
e long-term key to transforming our community
is to educate our women to their responsibilities,
not only as mothers, but also as community
members.
5. Re-orienting Policing Programs: develop cultural
competency of police in the community to
understand healing models.
6. Economic Development as Treatment: beyond
training people there is a need for incubating local
enterprises where community members can put
their energies.
7. Youth: a comprehensive youth healing and
development initiative to shift the underlying
pattern of life from dysfunction and abuse to
wellness and prosperity. (Bushie, n.d.; Dickie, 2000)
APPENDIX C - Mapping the Healing Journey
Case Study
Case studies of the Healing Movement in Eskasoni,
Esketemc, Hollow Water, Mnjikaning, Squamish, and
Waywayseecappo First Nations.
ese case studies clearly link colonization to trauma
that generated a wide range of dysfunctional and hurtful
behaviours (such as physical and sexual abuse) in First
Nations communities. rough the healing process,
communities build capabilities to perform as strong partners
in relationships with non-Aboriginal service professionals.
Without the condence and capacity for engaging in
culturally safe relationships with non-Aboriginal institutions
and professionals, equality in the relationship is impossible.
Dysfunction occurs at the community, family and
individual level; this study concretely identies steps and
processes to achieve healing and wellness in communities
at risk and crisis. Two remarkable examples are Hollow
Water and Alkali Lake who transformed from communities
in crisis to communities on their healing path. ese First
Nations have found a way to interrupt old dysfunctional
patterns and to introduce new patterns of living that are
sustainable and healthy.
ere have been a wide range of experiences, programs
and activities in the Aboriginal healing movement in the past
three decades. Here is a breakdown of the broad categories:
• Participation in traditional healing and cultural
activities.
• Culturally based wilderness camps and programs.
• Treatment and healing programs.
• Counselling and group work.
• Community development initiatives.
In both the Hollow Water and Alkali Lake case studies
the healing process began at the individual and family level.
Individual Healing Journey
Stage 1: e Journey Begins. e healing journey of
individuals often begins when they come face to face with
some inescapable consequence of a destructive pattern or
behaviour in their life or when they nally feel safe enough
to tell their story.
Stage 2: Partial Recovery. At this stage individuals have
mostly stopped their addictive behaviour, but the driving
forces that sustained it are still present.
Stage 3: e Long Trail. Once someone has reached a
hard-won sense of stability, it takes a great deal of courage,
discipline and motivation to continue on the healing journey.
Stage 4: Transformation and Renewal. Ultimately the
healing journey is about the transformation of consciousness,
acceptance and spiritual growth. (Lane et al., 2002)
e Four Seasons of Community Healing
Stage 1: Winter - e Journey Begins. is stage describes
the experience of crisis or paralysis that grips a community.
e majority of the community’s energy is locked up in
the maintenance of destructive patterns. e dysfunctional
behaviours that arise from internalized oppression and
trauma are endemic in the community and there may be an
unspoken acceptance by the community that this state is
somehow normal.
Stage 2: Spring - Gathering Momentum. is stage is like
a thaw, where signicant amounts of energy are released,
visible and positive shifts occur. A critical mass seems to
have been reached and the trickle becomes a rush as groups
of people begin to go through the healing journey together
which was pioneered by the key individuals in stage one.
ese are frequently exciting times. Momentum grows and
there is often signicant networking, learning and training.
e spirit is strong.
Stage 3: Summer - Hitting the Wall. At this stage, there
is the feeling that the healing movement has ‘hit the wall’.
Cultural Safety
Journal of Aboriginal Health, November 2009 35
Front-line workers are often deeply tired, despondent or
burned out. e healing process seems to be stalled. While
there are many people who have done healing work, there
are many more that seem left behind. ere is the growing
realization that it is not only individuals, but also whole
systems that need healing. ere may already be some
new initiatives in these systems (education, governance,
economics, justice, etc.). In some cases these initiatives
appear to become institutionalized and lose the sense of
spark and hope that characterized them in stage two. In
other cases, while awareness has begun to shift, old patterns
of working persist for lack of new (and culturally relevant)
models and strategies. e honeymoon stage is over as
the community begins the dicult work of transforming
deeply entrenched patterns and reconstructing a community
identity that was forged in oppression and dysfunction.
Stage 4: Fall - From Healing To Transformation. In Stage
Four, a signicant change in consciousness takes place. ere
is a shift from healing as “xing” to healing as “building,” as
well as from healing individuals and groups to transforming
systems. e sense of ownership for your own systems grows
and the skill and capacity to negotiate eective externally, and
reciprocal relationships develop. Healing becomes a strand
in the nation-building process. Civil society emerges within
communities and the Aboriginal community at large and a
shift of responsibility begins to take place. e impetus for
healing moves from programs and government to civil society.
Where to start with Communities at Risk and
Communities in Crisis?
When a community is at risk or in crisis, it is dicult to
know where to start. e healing journey provides some
concrete direction because both the community and
individual healing journeys are mapped out and modeled.
Often the journey begins when key individuals in the
community begin to question and challenge the status quo,
often making signicant transformations in their own lives,
by starting their own healing journey. ey reach out to
other individuals to provide mutual support and initiate
healing and crisis intervention activities. Another part of
the starting point is programs, where community members
and program sta combine their forces work closely to
develop a wider strategy. ese interagency groups plan and
implement collaborative interventions and initiatives.
Communities in Crisis: Starting Points
Both these starting points lead to healing at the individual
and community levels. Core groups form around health,
healing, sobriety, and wellness to begin the long-term
process of healing with the support from Elders and
outsiders. e following maps out the steps communities go
through in beginning and developing their healing journeys:
Drivers
• Dedicated key individuals (often women) respond
to their awareness that things are bad and there is
an alternative.
• Leaders and sta within programs are tasked with
addressing the consequences of some part of the
“crisis.”
• Visionary and courageous political leaders within
the community create a climate for healing.
Awareness
• ose driving the process often view the key tasks
as creating awareness of the need for healing and
may be largely focused on the outward face of the
problem (e.g. “alcohol is what is holding us back”).
Action Steps
• Personal healing and revitalization experiences;
formation of informal core groups and networks for
mutual support.
Indicators
• People begin their own healing journeys. A
growing number of people seek help for a particular
presenting issue or problem. Success/failure is
measured in stark terms (drinking vs. not drinking).
Risks
• Restraining forces, often from within the
community itself, ranging from denial of the issues
to overt and intimidating opposition directed at
key individuals.
Lessons Learned
e process of community and individual healing are more
clearly articulated with a recognizable pathway, steps and
indicators that are reproducible for communities at risk and
communities in crisis.
In the healing path individuals and communities rely on
traditional knowledge and ceremony to create safe and
healthy starting points.
Cultural Safety
36 Journal de la santé autochtone, novembre 2009
Policy Implications
Programs and strategies that support community healing
and wellness based on concrete steps and plans laid
out in Mapping the Healing Journey can be benecial to
communities at risk and in crisis and is an important
starting point when there is no apparent way forward.
Rationale
Mapping the Healing Journey oers some evidence that
this approach is eective in reducing rates of oenders
reoending and signicant cost savings of restorative
justice over incarceration of oenders. It also provides a
clear step-by-step process enabling communities at risk and
communities in crisis to start the healing journey at the
micro-level; how community members begin the process
that works for First Nations communities.
Project implementation
e process of the healing journey focuses on individual and
community healing combined with program coordination to
achieve collaborative interventions and initiatives. e case
studies make it clear that community members and program
managers can be trained to design, plan and implement
community healing.(Lane et al., 2002)
APPENDIX D - From Truth to Reconciliation
Case Study
Aboriginal Healing Foundation
A recent article by Marlene Brant Castellano confirms and
further elucidates the importance of safety to the individual
and community healing. She further explains the process of
reconciliation between Aboriginal and non-Aboriginal People.
Individuals who have suered trauma in childhood vary
in their ability to integrate their experiences into the
narrative of their lives. Reports from project participants
conrmed that healing from painful or suppressed
memories begins with awareness of barriers to a
satisfying life and beginning recognition of the sources.
Awareness can develop gradually or be precipitated
by a crisis such as a health problem, breakdown of a
marriage, or being charged with an oence. Projects
typically found that Legacy education about the history
and impacts of residential schools and group events
that centred on cultural activities supported readiness to
engage in therapeutic activities and relationships. In the
beginning stage of healing, survivors need to feel safe.
Establishing cultural safety, arming identities that had
been forcibly suppressed, was an important feature of
most projects.(Marlene Castellano Brant, 2008)
Castellano like others looks for a common thread,
and she points to developing cultural safety in healing,
that people often referred to as “spiritual.” She believes
that individuals talk about “dierent ways of making a
connection to something greater than themselves and
their individual griefs” (Brant Castellano, 2008, p. 398).
ey desire to connect with the “natural world, the stream
of history, family and community, or in some cases, with
a spiritual being who is friendly” (ibid). Trust lost by
colonization and residential schools is regained through a
long process that begins with personal and cultural safety.
e model for Stages of Community Healing is similar
to the model in Mapping the Healing Journey, it includes
the following steps:
1. Core group forms.
2. Gathering momentum.
3. “Hitting the wall.”
4. Healthy individuals / vibrant community.
Healing begins in an environment of safety and trust.
e transformation to a healthy state is made possible by a
climate of safety and an attitude of mutual trust.
Lesson learned
e healing process while understood and mapped-out
is found to be a long-term process: “Healing the legacy
of residential schooling, whether at the individual or
community level, is not a linear process” (Brant Castellano,
2008, p.394). e stages are approximate models of complex
real-life events and survivor’s progress and then circle
back on earlier stages when confronted with recurrent
challenges. For communities, change was described as “like
ripples unfolding in a pool, where each new circle contains
the previous ones” (ibid). e healing process begins with
individuals, often instigated by youth, then rallies at the
family level and nally nds a home at the community level.
Cultural Safety
Journal of Aboriginal Health, November 2009 37
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