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Are cultural safety denitions culturally safe? A review of 42 cultural
safety denitions in an Australian cultural concept soup
Mark Lock (Ngiyampaa) ( mark.lock@deakin.edu.au )
Deakin University https://orcid.org/0000-0002-9810-6086
Megan Williams (Wiradjuri)
University of Technology Sydney https://orcid.org/0000-0002-0969-2619
Atalanta Lloyd-Haynes (Saltwater, Gomeroi)
Oliver Burmeister
Charles Sturt University https://orcid.org/0000-0002-1800-9551
Heather Came
Auckland University of Technology https://orcid.org/0000-0002-1119-3202
Linda Deravin (Wiradjuri)
Charles Sturt University https://orcid.org/0000-0001-6181-3708
Jennifer Browne
Deakin University https://orcid.org/0000-0002-6497-2541
Maria Jose Lopez Alvarez
Troy Walker (Yorta Yorta)
Monash University https://orcid.org/0000-0003-0773-8035
Jessica Biles
Charles Sturt University https://orcid.org/0000-0002-0107-7435
Danielle Manton (Barunggam)
University of Technology Sydney
Holly Randell-Moon
Charles Sturt University https://orcid.org/0000-0002-9093-3837
Sophie Zaccone
University of New England https://orcid.org/0000-0003-4866-3877
Renée Otmar
Deakin University https://orcid.org/0000-0002-5464-4739
Elizabeth Kendall
Grith University https://orcid.org/0000-0003-2399-1460
Tara Flemington
Mid North Coast Local Health District https://orcid.org/0000-0002-3037-0462
Aqua Hastings
Australian Catholic University https://orcid.org/0000-0002-9532-8505
Jayne Lawrence (Wiradjuri)
Charles Sturt University https://orcid.org/0000-0003-2802-4162
Faye McMillan AM (Wiradjuri)
University of New South Wales https://orcid.org/0000-0002-9441-7805
Bindi Bennett (Gamilaraay)
Bond University https://orcid.org/0000-0002-0111-4670
Research Article
Keywords: cultural safety, First Nations Australians, structuration theory, denition, social policy, Indigenist
Posted Date: December 21st, 2021
DOI: https://doi.org/10.21203/rs.3.rs-1179330/v1
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Abstract
Cultural safety is a keystone reform concept intended to improve First Nations Peoples’ health and wellbeing. Are denitions of cultural safety,
in themselves, culturally safe? A purposive search of diverse sources in Australian identied 42 denitions of cultural safety. Structuration
theory informed the analytical framework and was applied through an Indigenist methodology. Ten themes emerged from this analysis,
indicating that cultural risk is embedded in cultural safety denitions that diminish (meddlesome modications and discombobulating
discourse), demean (developmentally dubious and validation vacillations), and disempower (professional prose, redundant reexivity, and
scholarly shenanigans) the cultural identity (problematic provenance and ostracised ontology) of First Nations Australians. We offer four
guidelines for future denitional construction processes, and methodology and taxonomy for building consensus based of denitions of
cultural safety. Using this approach could reduce cultural risk and contribute to improved workforce ability to respond to the cultural strengths
of First Nations Australians.
Introduction
Cultural safety is positioned as conceptual solution to address inequities experienced by First Nations peoples worldwide (hereafter, the phrase
‘First Nations Australians’ refers to Aboriginal and Torres Strait Islander peoples in colonial Australia). This movement began with kawa
whakaruruhau (cultural safety) [1] and its philosophical ramparts of ‘reexivity’ [2], ‘culture’ [3], ‘identity’ [4], and ‘power’ [5]. A cultural safety
reform agenda is evident in Canada, Australia, Colombia, and the United States [6–11]. In Australia, cultural safety denitions proliferate–
Australian denitions of cultural safety are contained in Table 1 (Supporting information Table 1)–and our question is: Are cultural safety
denitions culturally safe?
In the Australian social policy context, there is widespread support for implementing cultural safety within a broader cultural reform agenda
[12–14]. Example statements are: cultural safety is seen as being ‘critical to enhancing personal empowerment’ [15], for embedding in
‘Australia’s main health care standards’ [16], and that all Australian government agencies should ‘embed high-quality, meaningful approaches to
promoting cultural safety’ [17]. Rarely in government policy documents is a denition of cultural safety proffered. For example, while two
cornerstone policies for health and for social policy [17, 18] emphasise cultural safety, a denition is absent—and practitioners need to search
elsewhere for clarication.
Denitions as power points to frame meaning
Denitional clarity is important because denitions are ‘power points’ used to frame meaning. The embedded power of a cultural safety
denition appears potent when interpretations become the object of emotional public debate, as for the adverse reactions to the phrase
‘acknowledgement of white privilege’ in one denition (Table 1, Row 16) [19, 20]. Denitions are also powerful for professional accreditation. For
example, the Australian Health Practitioner Regulation Agency (AHPRA) has developed a denition of cultural safety (Table 1, Row 25) that
affects fteen registered health professions and the professional standards of over 800,000 registered health practitioners [21]. However, there
is little identication of how these professions will achieve cultural safety for accreditation beyond acknowledgment and recognition of the
concept [22].
Further, cultural safety denitions are already acknowledged as confusing [23–28]. Therefore, achieving clarity is necessary because, ‘incorrect
perceptions of this concept [cultural safety] may result in cultural risk’ [29]. Risk is agged where, ‘unsafe cultural practices comprise any action
that diminishes, demeans, or disempowers the cultural identity and well-being of the individual’ [30]. In this view, the act of creating a denition
is powerful.
Power of meaning dissolved in a cultural concept soup
The concept of power is a rampart of cultural safety, evident in the process of managing the transfer of power from the practitioner to the client
[31] and in analysing power imbalances [32]. Although there are many facets to consider about ‘power’ and cultural safety [33], in this paper, we
focus on discursive power; that is, the power of meaning-making through denitions. The creation of meaning through writing is powerful in
negative discourse about First Nations Australians [34–36] and in positive strength-based language [36, 37]. Therefore, examining cultural
safety denitions is a worthy exercise because practitioners (i.e., employees or service providers in any social policy domain) use denitions to
frame actions across their career pathways.
Denitional clarity is even more necessary when practitioners, in their search for cultural safety denitions, nd a veritable cultural concept soup
(Fig.2) in Australian social policy discourse. These colliding concepts include: cultural capability [38, 39], cultural learning [40, 41], cultural
competence [42, 43], cultural inclusiveness [44], cultural security [45], and cultural respect [46]. This soup of concept–consisting of numerous
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(and sometimes unknown) ingredients–may inuence practitioners’ capability to deliver culturally safe services by infusing their interpretive
schemes.
Interpretive schemes as ladle between structure and agency
In understanding the framing of actions and the potential risk of cultural safety denitions, Anthony Gidden’s Structuration Theory (ST) is useful
and is dened as ‘the structuring of social relations across time and space in virtue of the duality of structure’ [47]. In terms of ST, cultural safety
denitions occupy a modality ladle between agency and structure (Fig.1). That is, denitions are structurally positioned in policy discourse; in
various modalities such as practitioner regulations; and in agency through practitioner behaviours. When structural-level reforms require
practitioners to practice cultural safety, they dip a conceptual soup ladle (Fig.2) into various sources, as we do in this study, to inform their
attitudes.
Through the lens of ST, ‘interpretive schemes’ are patterns of behaviour through which agents act in society [48], and are simple rules for sense-
making [49] through which agents mobilise resources [50]. Cultural safety denitions are resources embedded in diverse sources. Giddens
(1984) writes about how power is imbued in language when creating meaning for the interpretive schemas of agents. For example, some argue
that cultural safety inuences attitudes and behaviours [51], which shows that denitions are vehicles of meaning for inuencing attitudes.
However, an important caveat is that the face value of denitions obscures the intentions of their authors. In investigating the context of
denitions (S3 Table 1), through the detailed exploration of research papers, it is apparent that some non-First Nations peoples have deep,
meaningful, and genuine connections that is not questioned here. The denitions offered by First Nations Australian authors are acknowledged
as being embedded in an ethic of advocating for their communities. Our analysis may be seen to undermine the values and spirituality of
authors, but that is certainly not our intention. Our aim is to respectfully highlight the potential detrimental consequences of cultural safety
narratives for First Nations peoples in Australia and offer guidelines for proper denitional development.
Methodology
Are cultural safety denitions culturally safe? To explore this question, we applied a theoretical orientation of Structuration Theory through an
Indigenist worldview. A group of culturally diverse authors (Supplementary information-Author Biographies) then conducted a purposive search
and thematic analysis of existing Australian cultural safety denitions.
Denitional debates and concept analysis
Denitional papers usually take the form of concept analysis and many related analyses already exist: holistic health [52], wellbeing [53], quality
improvement [54], Aboriginality [55, 56], and culture [57], cultural safety [29, 58], cultural humility [59], for ‘othering’ [60], cultural competence in
healthcare [61, 62], cultural sensitivity [63], and ‘health’ [64]. These analyses are usually devoid of reexivity about knowledge, discourse, power,
and culture. This body of research is also decient in First Nations Peoples’ worldviews in informing the underlying epistemological framework.
Our methodology addresses these gaps by drawing information from diverse sources (in contrast to only peer-reviewed literature), applying
theoretical specicity (Structuration Theory) and ensuring reexivity by and among authors particularly when working at the cultural interface
[65].
Theoretical orientation
The appeal of ST is its relational ontology, is seen in the denition of structuration (above), and which is seen in the ethic of ‘strong
relationships’ in Australian social policy, such as in calls for a First Nations Australian voice to Parliament [66], health systems reforms [67], and
cultural safety discourse [68–72]. The ‘structuration of social relations’ in ST, is evidence in restructuring social policy and systems for First
Nations Australians is noted in the 2020 National Agreement on Closing the Gap, which ‘signalled a new way of working to close the gap’ in life
expectancy and other indicators between First Nations and other Australians [17], and restructuring is a routine political process in social
policies relevant to First Nations Australians [73–77].
Giddens (1984) does not prescribe rules for converting structuration theory into a methodological framework, and a key task is to unpack ST
concepts into domains relevant to the eld of enquiry [78]. The framework for this study (Fig.1) shows Giddens’ diagram of structuration (1984:
29) on the right-hand side with the domains of agency (with concepts of communication, power, and sanction); modality (meaning through
interpretive schemes, facility, and norm); and structure (as rules and resources through signication, domination, and legitimation).
Fig.1: Transformation of structuration theory into a heuristic for analysis of cultural safety denitions
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Underlying this heuristic is the ‘duality of structure’, where ‘social structures are both constituted by human agency, and yet at the same time are
the very medium of this constitution’ [47]. That is, in unpacking ST concepts, legislation enables social policy systems which are transformed
into a governance context for organisations within which practitioners provide services to clients (left-hand side, Fig. 1). This is a mutually
interacting framework whereby agents (practitioners and citizens) in their interactions, simultaneously draw-on and inuence social policy
systems. They do so, according to Giddens, through routine social interactions that he describes through structuration concepts (identied in
Fig. 1, and described below):
Structures – are rules and resources which actors draw upon and use in the communication of meaning:
a. signication—the ‘symbolic orders/modes of discourse’ [47] such as denitions of cultural safety positioned in wider discourse of
cultural concepts,
b. domination – how codes of signication—such as racialisation [79]—are enacted using resources,
c. legitimation – the ‘social systems for normative regulation’ [79], such as reected in legal institutions [47].
Modality - refers to, for example, writing and conversation as modalities of signication [80]:
a. interpretive scheme – as described above,
b. facility – refers to the access of ‘media’ that agents use to develop stocks of knowledge, such as the use of the English language as a
facility for the communication of meaning, or accreditation standards as a facility for conveying practice expectations,
c. norm – evident when an actor needs to explain their actions by drawing on social norms such rules of ‘race norms’ [79].
Agency – the capability, often reected within the individual, to take part in and inuence routines of daily life [47]:
a. communication and power – including communication of denitions, which are themselves power points of inuence, and
b. sanction – the restraining aspects of power experienced as, for example, the use of ‘overt physical violence to the expressions of mild
disapproval’ [47].
Giddens (1984) makes clear that these concepts are nondeterministic abstractions useful in the organisation of analysis of social interactions.
These understandings provided a sensitising lens for the study rather than stepwise instructions for empirical analysis.
Data collection
Australian denitions of cultural safety were identied by searching different sources (December 2020 to July 2021, with supplemental
searches afterwards to detect new denitions) using the keywords of ‘denition’ and cultural safety, and their Boolean operators. The webpage
search string was ‘site:au denition “cultural safety” dene “culturally safe”’, which returned hundreds of thousands of pages, of which the rst
50 pages (500 items) were scanned for results. This meant that a single click on the hyperlink opened to the relevant page referencing the
keywords. We also searched academic database platforms—Informit (e.g., ATSIHealth, APAIS-ATSIS; Indigenous Collection); CINAHL Complete;
PubMed; Scopus, Medline, ProQuest (Australia & New Zealand Database), EBSCOhost, and OVID; and with parameters of ‘full text’ and ‘no date’
range. All Australian-only sources were included with denitions extracted into a table where a taxonomical notation (Appendix 1, Table 1) was
devised to allow cross-reference and comparison between denitions.
Thematic development
The thematic development process followed open-ended ‘online’ yarning [81, 82] between the authors, and in larger groups that included authors
and others in our networks. This identied the theory and research question. It was followed by data collection and analysis, and cycles of
written feedback. This process is aligned with an Indigenist methodology of knowledge production, and especially responds to the call that
‘Indigenous perspectives must inltrate the structures and methods of the entire research academy’ [83]. This demands an ethic of resistance as
an emancipatory imperative in Indigenist research, the cultural and political integrity of Indigenous research, and the privileging of First Nations
Australians’ knowledge and voices in research design [84]. Hence, these values are imbued in the category names for each theme.
Results
The extracted denitions are presented in Appendix 1 (Table 1), and the resulting themes are shown diagrammatically as a metaphorical
cultural concept soup (Fig.2). In Fig.2, diverse stakeholders, consciously or unconsciously, bring with them different cultural denitions to their
work, and use what they think is the ‘cultural safety ladle’ to stir the soup. The thematic aromas that arise from the soup diffuse into social
policy discourse to create ethereal meanings about which cultural concept–or group of concepts–are crucial to the success (or failure) of
cultural reforms.
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Denitional diversity
Our search yielded 42 denitions of cultural safety (Table 1) in social policy about First Nations Australians. The denitional diversity appeared
to begin with the rst published denition of cultural safety, namely Eckermann’s 1992 book ‘Binan Goonj: Bridging Cultures in Aboriginal
Health’, as reprinted in 1994 [85]. Hence, it is the rst entry in Table 1 (Row 1). A taxonomy was created for tracking the source of denitions
AKE-dCSaf-AU (Ann Katrin-Eckermann, denition of cultural safety, Australia). The second denition is Robyn Williams’, published in the journal
article, ‘Cultural Safety – What Does it Mean for Our Work Practice?’ (Williams, 1999): RW-dCSaf-AU (Table 1, Row 2).
Numerous modications occur to Williams’ denition over the years, which is not the case for Eckermann’s denition. There are seven
modications to Williams’ denition (Table 1, Rows 3, 11, 15, 17, 19, 23, and 26). In our taxonomy, MBS-dCSaf(RW-dCSaf2)-AU, means that
Maryann Bin-Sallik modied Robyn Williams’ denition. This occurs were Bin-Sallik extracted a paragraph from an unpublished paper of
Williams’ [86] and reframed the paragraph (located in Appendix 3, p. 15) as Williams’ denition [87]. Other denitions of cultural safety (not
Williams’ or Eckermann’s) were also modied by subsequent authors (Table 1, Rows 21, 24, 28, and 42).
The denitions also reect diverse points and pathways within health (e.g., policy, hospital, nursing and midwifery, health workers, doctors,
health equity, alcohol programs, health practitioners, women’s safety, general practice, suicide prevention), family and child safety (e.g., social
work, education system, child care and young people, family violence), the mining industry, legal centres and legal aid, workplace health and
safety, Australian trade and investment, Australian rules football, and program evaluation and libraries. This denitional diversity holds
implications for ‘governance’ and ‘legitimation’ (Fig.1) in the sense that denitions are vehicles of meaning for the governance actions driving
organisational reforms that ow on to practitioner service delivery.
Developmentally dubious
Except for the AHPRA denitional development process (Table 1, Row 25), the processes for constructing denitions were opaque (dubious) in
that no empirical, theoretical, or methodological processes are described for their construction (other than the fact that some draw-on earlier
authors). There are no publicly available explanations of how denitions were developed, with whom they were developed, and whether any
First Nations Australian community engagement occurred during the process of delineation. This lack of engagement and culturally informed
process has implications for the ‘interpretive scheme’ concept of structuration (rst level of Fig.1) because community needs are not informing
denitions and, thereby, guidance for practitioners to respond to community needs.
Problematic provenance
The cultural provenance of the denitions shows that many (n=14) (Table 1) are transformed from kawa whakaruruhau, a Māori First Nations
concept from Aotearoa/New Zealand, and not from a concept of First Nations Australians (Table 1, Rows 1, 2, 3, 7, 11, 14, 15, 17, 19, 20, 23, 26,
27, and 30), such as the Wiradjuri concept of Nyaa-bi-nya: to examine, try, and evaluate [88]. Almost half of the denitions (n=20, Table 1, Rows
4, 5, 6, 8, 9, 10, 12, 13, 16, 18, 29, 31, 32, 33, 34, 35, 36, 37, 38, and 39) have unknown provenance. There are nine denitions (Table 1, Rows 21,
22, 24, 25, 28, 34, 39, 41, and 42) whose cultural origins are Australian and New Zealand (but not kawa whakaruruhau). This has implications
for the ‘signication’ concept of structuration (Fig.1) and social policy systems, because such ‘problematic provenance’ suggests the possibility
of cultural appropriation [89] and signies the devaluing of First Nations Australian ways of knowing.
Ostracised ontology
First Nations Australians are among the world’s oldest living cultures [90] and have local language terms for health and wellbeing. For example,
there is Kaurna language: Yaitya Purruna/‘our own health and wellbeing’ [91]; Wiradjuri language: Waluwin/‘health and wellbeing’ [92]; Walpiri:
wankaru/ ‘to promote and strengthen the life of Aboriginal people as a means of ensuring their survival and growth’ [93]; Aranda language:
Kurruna Mwarre Ingkintja/‘good spirit men’s place’ [94], and Wirringa Baiya/‘women speak’ [95]. None of the denitions in Table 1 make
reference to First Nations Australian languages to indicate that their meanings are based on translation of local worldviews. This ‘ostracised
ontology’ has implications for the ‘domination’ concept of structuration and ‘legislation’ (Fig.1, Level 1) because infusing legislation with
cultural power should be based on the strengths of First Nations Australian cultures.
Validation vacillations
Validation involves stakeholder assessment of measurement tools to ensure they are culturally acceptable [26, 96]. First Nations Australians
challenge the underlying Western cultural construct of many instruments [97–100]. None of the denitions (Table 1) come with information
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about their methodologies of cultural validation: what was the instrument used to validate their process and their denitions? Such ‘validation
vacillations’ have implications for the ‘sanction’ concept of structuration (Fig.1, Level 3) and the types of social services provided because who
decides (sanctions) a service is culturally safe are First Nations Australians, who expect those services to reect their cultural values.
Professional prose
Based on the individual (as opposed to organisational) authors the denitions are rendered in English and through the lenses of non-First
Nations peoples (n=7, Table 1, Rows 1, 2, 14, 23, 30, 31, and 33) who were professionals with higher education qualications, and who were
employed by mainstream organisations. Similarly, other denitions were authored by First Nations experts (n=5, Table 1, Rows 9, 14, 26, 29, and
39). Even the First Nations authors are based in similar settings, though only a few authors are First Nations Australians (Maryann Bin-Sallik,
Gregory Phillips, BJ Newton, Larissa Behrendt, and Sharon Gollan), but also with professional education and qualications.
The result is where ‘professional prose’ structures the locus of power to rest with professionals rather than First Nations communities or service
users. It is notable that almost all (except Row 30, Table 1) denitions developed by individual authors avoid referencing their own professional
standing and power, despite the philosophical rampart of ‘reexivity’. Other denitions reference professional/provider power (n=3, Table 1,
Rows 21, 27, 30) and power imbalances/sharing/differentials (n=10, Table 1, Rows 8, 10, 16, 24, 25, 28, 34, 37, 40, and 41). This has
implications for the ‘agency’ and ‘power’ concepts of structuration theory (Fig.1, Level 3) because of the power of writing in creating meaning
that inuences practitioner attitudes and their practices.
Scholarly shenanigans
The denitions of cultural safety also suffer poor standards of attribution and citation (n=10, Table 1; Rows 2, 3, 12, 15, 17, 19, 23, 28, 40, and
41). Examples of ‘scholarly shenanigans’ are common. For instance, in an article about the importance of cultural safety to social work policy,
Thompson and Duthie [101] quote Williams’ (1999) denition but attribute it to an article by Ramsden (1992), which does not contain any
denition [102], and this shenanigan also occurs in an article by Elvidge and colleagues [27]. The denition AIHW-dCSaf (Table 1, Row 27) is
incorrectly referenced to Papps and Ramsden [103], which is also incorrectly cited as the source of a so-called ‘denition’ (Table 1, Row 41).
There is one incorrect citation of Williams’ (1999) denition of cultural safety as Williams (2008) (Table 1, Row 19) and an internet search
revealed n=124 instances where this incorrect reference was repeated [i.e., found by entering the incorrect reference: ‘Williams, R. (2008).
Cultural safety: what does it mean for our work practice?’]. The denition by Williams (1999) is often attributed to Eckermann and colleagues
(1994) (Table 1, Row 2, 23, and 26) [see for example 104]. The work is also misattributed in The National Best Practice Framework for
Indigenous Cultural Competency in Australian Universities [43], and in academic articles [105, 106]. If scholars checked primary sources, they
would have seen Eckermann’s denition (Table 1, Row 1) bears no resemblance to Williams’s denition (Table 1, Row 2). This has implications
for the ‘modality’ and ‘facility’ concepts of structuration (Fig.1, Level 2) because the inaccuracies are repeated in cultural safety discourse, a
facility of meaning.
Meddlesome modications
The denitions contain different ingredients (Table 1) with no explanation for their selection. In the health domain, these ‘meddlesome
modications’ of the concepts not only risk stultifying the cultural avour of the soup, but also affect how denitions are interpreted. The
modications can be seen in the selection of key ingredients excised from each denition:
a. recognised, assured, reects, you/your culture, language, customs, attitudes, beliefs, and preferred ways (AKE-dCSaf, Row 1)
b. determined, individuals, families, communities, practise, reection, health practitioner, knowledge, skills, attitudes, behaviours, power
differentials, safe, accessible, responsive, and racism (AHPRA-dCSaf, Row 25)
c. dened, health consumer, individual, experience, care, ability, access services, and raise concerns (AIHW-dCSaf, Row 27)
d. environment, diverse background, feels, valued, and accepted (LB-dCSaf, Row 29)
The meddlesome modications hold implications for the ‘communication’ concept of structuration (Fig.1) with the rationale that the selection
of words (and who selects them) is signicant for the communication of meaning to stakeholders and their organisations. Interestingly, the
concepts of power (n=7), culture (n=12), reexivity (n=6), and identity (n=20) are non-uniformly distributed and show selective word choices by
authors.
Discombobulating discourse
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The denitions in Table 1 contain a confusing of meanings. For example, ANMC-dCSaf states ‘regardless of race or ethnicity’ (Table 1, Row 4)
whereas Eckermann’s denition implores ‘the need to be recognised within the healthcare system’ (Table 1, Row 1) and CATSINAM-dCSaf (Table
1, Row 16) states that it, ‘represents a key philosophical shift from providing care regardless of difference, to care that takes account of peoples’
unique needs’. Thus, while cultural safety may be a commonly used phrase, the ‘discombobulating discourse’ and denitional diversity within
different policy points demonstrates the potential risk of divergent meanings through the ‘interpretive scheme’ concept of structuration and
‘practitioner-client interaction’ (Fig.1, Levels 2 and 3). Then, when communicating with clients, practitioners may speak from a standpoint of
either disregard or regard for race and justify both as correct choices by referencing the relevant denition.
Redundant reexivity
All denitions (except the APHRA denition) occur without being reexive to cultural diversity, power, and identity. The individual authors of
organisational denitions (Table 1) are unknown, in that they do not identify themselves or their cultures, and in doing so demonstrate
‘redundant reexivity’ (n=28; Table 1, Rows 4, 5, 6, 7, 8, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 22, 24, 25, 27, 28, 32, 34, 35, 36, 37, 38, 40, and 42).
This invisibility of authors’ cultural identities prevents understanding of their cultural worldviews through which the denitions were developed.
There are also whole-of-organisation authors (n=23; Table 1, Rows 4, 5, 10, 11, 12, 13, 17, 19, 20, 21, 22, 24, 25, 27, 28, 32, 34, 35, 36, 37, 38, 40,
and 42) with western colonial hierarchical governance structures that are at odds with First Nations community governance practices
(Panaretto, Wenitong et al., 2014). There are some non-government organisations based on First Nations professional interests and advocacy
(n=3; Table 1, Rows 7, 10, and 16), but where governance structures are still hierarchical based in colonial models. In contrast, four Aboriginal
community controlled organisations offered denitions (VACCA in Row 6, VACCHO in Row 8, CAPSC in Row 17, and SNAICC in Row 18). None
of the whole-of-organisation denitions are accompanied by reexive statements about the philosophical implications of infusion their different
governance structures with cultural safety.
Overall, the organisational authorship processes, and the resulting cultural safety denitions, lack grounding in the frequent call for reexivity so
often made by authors of cultural safety denitions. This has implications for the ‘norm’ concept of structuration (Fig.1, Level 2) because it
signies a convention for reexivity to be an optional, rather than essential, feature of cultural safety.
Fig.2: Cultural concept soup with thematic results
Discussion
The ten themes emanating from the cultural concept soup (Fig.2) whiff of cultural risk. This analysis substantiates the claim that the
conceptual clarity of cultural safety is being diminished [107], particularly through the morphing of its original intent [108], and thus undermines
its inuence as a transformative moral discourse [8]. Cultural risk refers to ‘any action’ which may diminish, demean, or disempower cultural
identity – including the action of creating denitions. The cultural risk in denitions was assessed using Giddens’ Structuration Theory as the
analytical frame, and structuration concepts that have been used to tease out the implications for Australian cultural safety discourse.
Structural implications
Australian Practitioners searching for guidance on cultural safety are likely to be confronted with at least 42 denitions of cultural safety.
Although denitional diversity may be consistent with the philosophy of cultural safety, the increased availability of inconsistent information
could be problematic in moving from denition to practice. As Ramsden (1990) wrote, ‘like ethical safety, cultural safety must be interpreted
according to each event’ [109]. This view legitimises diverse interpretations of cultural safety philosophy, which aligns with the cultural diversity
of First Nations Australians, but it also presents cultural risks.
Interestingly, cultural diversity is not reected in the problematic provenance of the denitions, where ‘provenance’ is the notion that an idea
seeded in a locale (following Giddens) has unique properties of cultural context that cannot be transplanted to different environments. It is
problematic for Australian social policy actors to signify Māori ontology embedded in cultural safety [89] over First Nations Australians’
Country-specic ontologies that need to be directing and informing policy and practice [110]. No stronger signication of cultural provenance is
seen elsewhere than in the expressions of cultural voice of First Nations Australians through their traditional languages [111].
In terms of domination, the denitions inect an ostracised ontology that disavows First Nations Australians’ worldviews. This norm is
consistent with current Australian debates about whether or not to embed a First Nations Australian voice in Australia’s national Parliament
through Constitutional reforms [112]. The debates centre on the fundamental right [113] of First Nations Australians’ cultural values to direct
legislation, to challenge the dominance of non-First Nations Australians’ worldviews, and to infuse decisions about rule-making and resource-
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allocation. Therefore, calls to legislatively embedded cultural safety in healthcare standards [16] could enable further disempowerment, and this
risk stimulates the need for better translation of First Nations Australians’ worldviews in developing cultural denitions.
Modality implications
Almost all denitions of cultural safety are developmentally dubious because, in their construction, no information is given to evidence the
genuine engagement with First Nations Australian consumers and community-led organisations. This undermines the denitions’ legitimacy for
incorporation into stocks of knowledge and interpretive schemes. The partial exception is the AHPRA denition (Table 1, Row 23) which was
based on a public consultation process, and both the process and outcomes were published (Australian Health Practitioner Regulation Agency,
2019a, 2019b). However, behind all denitions is a validation vacillation that disrespects the process of cultural validation wherein ‘theories and
instruments need to be ‘grounded’ within that culture, if they have to be considered valid’ [114]. These problems pivot on the modality axis to
inuence the structure and agency of cultural safety denitions, which occur lumped in with the cultural concept soup (Fig.2) where other
cultural concepts, such as cultural competence, also suffer from ‘ambiguity and lack of denition’ [115].
Furthermore, scientic rigour is lacking in the development of these denitions, as evident in the scholarly shenanigans. Scholars are called on
to construct reliable evidence [116] that practitioners interpret and embed into their attitudes. If scholarly publications about First Nations
Australians’ cultural safety are of poor quality, it is axiomatic that higher education curriculum and professional training and practice will suffer
[117]. This situation points to the facility of the evidence base being faulty, which then ramies through each related concept of structuration.
Practitioners, expected to practice evidence-based care [118], may not know to question the quality of cultural safety denitions, and if they are
non-First Nations, may not believe they have any authority to do so.
Agency implications
One responsible line of questioning for practitioners would be to ask if a denition they adopt/ascribe to ‘ts with the familiar cultural values
and norms of the person[s] accessing the service’ (VACCHO-dCSaf, Table 1, Row 8), because there is scant evidence that denitions reect the
cultural voices of First Nations Australians. The risk is that the 42 denitions and their discombobulating discourse inuences practitioners’
interpretive schemes and erode condence in their interactions with First Nations clients.
The implication of denitional diversity and discombobulated discourse should not be under-estimated. The Australian Nursing and Midwifery
Standards of Practice states that, ‘guidance around cultural safety in the codes sets out clearly the behaviours that are expected of nurses and
midwives’ [119]. Achieving clarity of behaviours is illogical when practitioners face confusing messages and meanings embedded in diverse
denitions. Reliable guidance is, moreover, complicated by the shenanigans of scholars, their meddlesome modications, and their redundant
reexivity about the power of words.
The selection of words and who selects them are signicant for the communication of meaning in interaction, as evidenced in debates about
holistic health versus Western medicine [52]. For example, a practitioner may wonder about ‘decolonisation’ and ‘acknowledgement of white
privilege’ being in one denition (NMFBA-dCSaf, Table 1, Row 24) but not in another denition (ANMC-dCSaf, Table 1, Row 4). Considered word
choice is necessary in constructing meaning to respect cultural provenance–witness the cultural power of kawa whakaruruhau/cultural safety
[109].
Word choice through professional prose dominates transformations of the philosophy of cultural safety, and risks being a conscious or
unconscious discursive tactic to reinforce professional power. This contrasts with human rights-informed literature that asserts the importance
of addressing power imbalances between practitioners and clients—as AIHW-dCSaf states that cultural safety, ‘is dened by the health
consumer’s experience’ (Table 1, Row 26). However, it is nursing health professionals who have led cultural safety politics [119], in an Australian
political environment of consumer and community-based advocacy [74, 120, 121]. This also indicates and an incongruent interplay between
transitions from the oral narratives historically practiced about caregiving in health care [52], compared with written narratives from those in
more powerful (often scholarly) positions, which may lead to interpretive differences in meaning. Therefore, a key challenge for practitioners is
to reect on the balance of cultural identity, profession power, and community voices evident (or not) in denitions.
Several denitions of cultural safety show that the assessment of a safe service needs to be dened by those who receive the service (Table 1,
NATSIHWA-dCSaf, Row 10; LIME-dCSaf, Row 21; AIHW-dCSaf, Row 27; NTH-dCSaf, Row 40). First Nations Australians’ community engagement
should occur at the time of creating the denitions of cultural safety, not only at the point of assessing the outcomes of services. The absence
of cultural validation in denitions developed by experts and professionals, sanctions (Fig.1) an ethic of excluding clients’ voices. This ethic
disabuses governance of client agency and their feelings about what is culturally safe.
Page 10/17
Denitions enable cultural risk
Based on this analysis of publicly available online documents, Australian cultural safety denitions – on face value – are actually culturally
unsafe. The themes show that cultural risk is embedded in cultural safety denitions that diminish (meddlesome modications and
discombobulating discourse), demean (developmentally dubious and validation vacillations), and disempower (professional prose, redundant
reexivity, and scholarly shenanigans) the cultural identity (problematic provenance and ostracised ontology) of First Nations Australians.
Clarifying the cultural concept soup
Clarication is important to pursue because cultural safety is but one of many cultural concepts circulating in the Australian cultural reform
agenda [12], and is also subject to criticism from transcultural nursing proponents, ‘the notion of cultural safety is conceptually problematic,
poorly understood, and under-researched’ [122]. Furthermore, cultural safety is conated into many other terms including cultural security [123],
cultural competence [124], and cultural capability [125]. Our methodology, particularly the use of Structuration Theory, could lead to better
evaluation of cultural training programs through improved methodological rigour [126] applied to the development of denitions that inform
training program design.
Reective guidelines
We serve-up four guidelines for the development and use of cultural safety denitions, namely to reect on language power, to describe the
process, to epitomise First Nations Australians’ community voices, and to ensure cultural rigour.
1. Reect on the power of language: Language is a weapon for creating meaning to control and shape social policy—be guided by examples
of genuine writing between First Nations and non-First Nations authors, such as Povey and Trudgett (2019), and the work of academics
who apply cultural quality appraisal tools [127].
2. Describe the process: Clearly explain the steps used in denition development, as recently outlined [128]. The AHPRA process is an example
of transparency and accountability through publications [129-132].
3. Epitomise the cultural voice: The voice of First Nations Australians is available through oral forms of communication, such as yarning
[133], the results of which could be to focus on the articulation of local First Nations’ languages and their meaning for cultural safety [134].
4. Ensure cultural rigour: The cultural rigour [135] of the denitional development process must be guided by relevant critical thinking tools
[88, 136, 137], cultural validation methods [96], and Indigenous theories [65, 83, 138].
Future research is needed to assess the interpretations of cultural safety denitions in the real-world machinations of inter-cultural
communications: how they are used in practice, if they affect interactions, and if First Nations Australians feel they promote cultural safety.
Limitations
This study is based on a purposive search and rigorous systematic reviews may nd even more Australian denitions. While Structuration
Theory has provided a new perspective from which to view cultural safety denitions, it is a western sociological concept not developed with or
by colonised peoples. Caution must also be exercised to avoid over-ascribing the signicance of denitions as deterministic of human
intentions.
Conclusion
This study revealed ten cultural risks based on an analysis of 42 denitions of Australian cultural safety gathered from an online search of
diverse sources. Our ndings suggest the publicly available documents served up to Australian practitioners represent a ‘cultural concept soup’
emanating confusing aromatic themes. This may affect practitioners’ application of cultural safety with First Nations Australian clients, who
could be placed at cultural risk. We propose a methodology and taxonomy to advance a social science of denitional analysis. Open to
scholarly debate, our intention is to contribute to building a high-quality evidence base so that claims about cultural safety can rest on culturally
rigorous methodology. This could reduce cultural risk and contribute to improved workforce ability to address the inequities experienced by First
Nations Australians.
Declarations
Acknowledgements
Page 11/17
Thank you to Ms Sophie Kinna for her research assistance, Ms Jodie Lea Matire for her cultural perspectives in writing and publishing, and Ms
Janine Dunleavy for deadly critical thinking about Aboriginal cultural anthropology.
Competing interests
The authors declare no competing interests.
References
1. Ramsden IM. Cultural Safety and Nursing Education in Aotearoa and Te Waipounamu [dissertation]. Wellington: Victoria University; 2002.
2. Fisher M, Mackean T, George E, Friel S, Baum F. Stakeholder perceptions of policy implementation for Indigenous health and cultural safety:
A study of Australia's ‘Closing the Gap’ policies. Aust J Public Adm 2021;80:239–60. doi: 10.1111/1467-8500.12482.
3. Cox LG, Simpson A. Cultural safety, diversity and the servicer user and carer movement in mental health research. Nurs Inq
2015;22(4):306–16. doi: 10.1111/nin.12096.
4. Fast E, Drouin-Gagné M-E, Bertrand N, Bertrand S, Allouche Z. Incorporating diverse understandings of indigenous identity: Toward a
broader denition of cultural safety for urban indigenous youth. AlterNative. 2017;13(3):152–60. doi: 10.1177/1177180117714158.
5. Fraser S, Grant J, Mackean T, Hunter K, Holland AJA, Clapham K, et al. Burn injury models of care: A review of quality and cultural safety for
care of Indigenous children. Burns. 2018;44(3):665–77. doi: 10.1016/j.burns.2017.10.013.
. Gerrard JM, Godwin S, Chuter V, Munteanu SE, West M, Hawke F. Release of the National Scheme's Aboriginal and Torres Strait Islander
Health and Cultural Safety Strategy 2020-2025; the impacts for podiatry in Australia: a commentary. J Foot Ankle Res. 2021;14(1):38. doi:
10.1186/s13047-021-00466-8.
7. Doutrich D, Arcus K, Dekker L, Spuck J, Pollock-Robinson C. Cultural safety in New Zealand and the United States: looking at a way forward
together. J Transcult Nurs. 2012;23(2):143–50. doi: 10.1177/1043659611433873.
. Smye V, Browne A. 'Cultural safety' and the analysis of health policy affecting aboriginal people. Nurse Res. 2002;9(3):42–56. doi:
10.7748/nr2002.04.9.3.42.c6188.
9. Roy-Michaeli M. Cultural Safety Nursing Education in Canada: A Comprehensive Literature Review [dissertation]. Vancouver: University of
British Columbia; 2007.
10. Curtis E, Jones R, Tipene-Leach D, Walker C, Loring B, Paine S-J, et al. Why cultural safety rather than cultural competency is required to
achieve health equity: a literature review and recommended denition. Int J Equity Health. 2019;18(1):174. doi: 10.1186/s12939-019-1082-
3.
11. Pimentel J, Cockcroft A, Andersson N. Impact of game jam learning about cultural safety in Colombian medical education: a randomised
controlled trial. BMC Med Educ. 2021;21(1):132. doi: 10.1186/s12909-021-02545-7.
12. Lock M, Burmeister O, McMillan F, Whiteford G. Absence of rigorous evidence undermines cultural safety reforms. Aust J Rural Health.
2020;28(1):4–5. doi: 10.1111/ajr.12606.
13. Thomson N. Cultural respect and related concepts: a brief summary of the literature. Australian Indigenous Health Bulletin. 2005;5(4):1–11.
14. Mohamed J, West R. Creating an Indigenous-led movement for Cultural Safety in Australia [Internet]. Croakey; c2017 [cited 2021 Dec 16].
Available from: https://croakey.org/creating-an-indigenous-led-movement-for-cultural-safety-in-australia/.
15. Williams R. Cultural safety – what does it mean for our work practice? Aust N Z J Public Health. 1999;23(2):213–4. doi: 10.1111/j.1467-
842x.1999.tb01240.x.
1. Laverty M, McDermott DR, Calma T. Embedding cultural safety in Australia's main health care standards. Med J Aust. 2017;207(1):15–6.
doi: 10.5694/mja17.00328.
17. Joint Council on Closing the Gap. National Agreement on Closing the Gap. Canberra: The Council; 2020 Jul. 47 p.
1. Australian Government Department of Health. National Aboriginal and Torres Strait Islander Health Plan 2013-2023. Canberra: The
Government; 2013 Jul. 61 p.
19. Congress of Aboriginal and Torres Strait Islander Nurses and Midwives. The Nursing and Midwifery Aboriginal and Torres Strait Islander
Health Curriculum Framework. Canberra: The Congress; 2017, 30 p.
20. Stewart S. White Privilege: What's 'The Code' Got to Do With it? Australian Midwifery News. 2018 Jun. 18(2):53-.
21. Australian Health Practitioner Regulation Agency. AHPRA Annual Report 2019/20. Melbourne: The Agency; 2020, 156 p.
22. Milligan E, West R, Saunders V, Bialocerkowski A, Creedy D, Rowe Minniss F, et al. Achieving cultural safety for Australia’s First Peoples: a
review of the Australian Health Practitioner Regulation Agency-registered health practitioners’ Codes of Conduct and Codes of Ethics. Aust
Health Rev. 2021;45:398–406. doi: 10.1071/AH20215.
Page 12/17
23. Polaschek NR. Cultural safety: a new concept in nursing people of different ethnicities. J Adv Nurs. 1998;27:452–7. doi: 10.1046/j.1365-
2648.1998.00547.x.
24. Hart A, Hall V, Henwood F. Helping health and social care professionals to develop an ‘inequalities imagination’: a model for use in
education and practice. J Adv Nurs. 2003;41(5):480–9. doi: 10.1046/j.1365-2648.2003.02555.x.
25. Milne T, Creedy DK, West R. Development of the Awareness of Cultural Safety Scale: A pilot study with midwifery and nursing academics.
Nurse Educ Today. 2016;44:20–5. doi: 10.1016/j.nedt.2016.05.012.
2. Ryder C, Mackean T, Ullah S, Burton H, Halls H, McDermott D, et al. Development and validation of a questionnaire to measure attitude
change in health professionals after completion of an Aboriginal health and cultural safety training programme. Aust J Indig Ed. 2017:1–
15. doi: 10.1017/jie.2017.37.
27. Elvidge E, Paradies Y, Aldrich R, Holder C. Cultural safety in hospitals: validating an empirical measurement tool to capture the Aboriginal
patient experience. Aust Health Rev. 2020;44(2):205–11. doi: 10.1071/AH19227.
2. Con J. Rising to the challenge in Aboriginal health by creating cultural security. Aborig Isl Health Work J. 2007;31(3):22.
29. Bozorgzad P, Negarandeh R, Raiesifar A, Poortaghi S. Cultural Safety: An Evolutionary Concept Analysis. Holist Nurs Pract. 2016;30(1):33–
8. doi: 10.1097/HNP.0000000000000125
30. Nursing Council of New Zealand. Guidelines for cultural safety, the Treaty of Waitangi, and Maori health in nursing education and practice.
Wellington: The Council; 2011 Jul. 24 p.
31. Møller H. Culturally safe communication and the power of language in Arctic nursing. Études/Inuit/Studies. 2016;40(1):85–104. doi:
10.7202/1040146ar.
32. National Aboriginal Health Organization. Cultural competency and safety: A guide for health care administrators, providers and educators.
Ottawa: The Organization; 2008 Jul. 33 p.
33. Guinaran RC, Alupias EB, Gilson L. The practice of power by regional managers in the Implementation of an Indigenous Peoples health
policy in the Philippines. Int J Health Policy Manag. 2020. doi: 10.34172/ijhpm.2020.246.
34. Fforde C, Bamblett L, Lovett R, Gorringe S, Fogarty B. Discourse, Decit and Identity: Aboriginality, the Race Paradigm and the Language of
Representation in Contemporary Australia. Media Int Aust. 2013;(149):162–73. doi: 10.1177/1329878X1314900117.
35. Anderson J, Perry J, Blue C, Browne A, Henderson A, Khan KB, et al. "Rewriting" Cultural Safety within the Postcolonial and Postnational
Feminist Project: Toward New Epistemologies of Healing. Adv Nurs Sci. 2003;26(3):196–214. doi: 10.1097/00012272-200307000-00005.
3. Fogarty W, Lovell M, Langenberg J, Heron M-J. Decit Discourse and Strengths-based Approaches: Changing the narrative of Aboriginal
and Torres Strait Islander health and wellbeing. Melbourne: The Lowitja Institute, National Centre for Indigenous Studies. 2018; May 36 p.
37. Passing the Message Stick Organisation. Passing the Message Stick: A Guide for Changing the Story on Self-determination and Justice.
Online: The Organization; 2021 Aug. 125 p.
3. Australian Public Service Commission. Aboriginal and Torres Strait Islander Cultural Capability: A Framework for Commonwealth Agencies.
Canberra: The Commission; 2015, 17 p.
39. Queensland Government Department of Health. Aboriginal and Torres Strait Islander Cultural Capability Framework 2010-2033. Brisbane:
The Department; 2010, 20 p.
40. South Australian Government Department of Health and Ageing. SA Health Aboriginal Cultural Learning Framework. Adelaide: The
Department; 2017, 22 p.
41. Western Australia Department of Health. WA Health Aboriginal Cultural Learning Framework. Perth: The Deparment; 2012, 6 p.
42. Victorian Aboriginal Child Care Agency, Victorian Government Department of Human Services. Aboriginal Cultural Competence Framework.
Melbourne: The Agency; 2008, 58 p.
43. Universities Australia. National Best Practice Framework for Indigenous Cultural Competency in Australian Universities. Canberra: The
Organization; 2011, 422 p.
44. South Australian Department for Communities and Social Inclusion. Aboriginal Cultural Inclusion Framework - Policy Statement. Adelaide:
The Deparment; 2005, 4 p.
45. Northern Territory Health. Aboriginal Cultural Security Policy. Darwin: The Territory; 2016, 8 p.
4. Australian Health Ministers' Advisory Council. Cultural Respect Framework for Aboriginal and Torres Strait Islander Health, 2016-2026.
Canberra: The Council; 2016, 21 p.
47. Giddens A. The constitution of society: Outline of the theory of structuration. Berkeley: University of California Press; 1984.
4. McGarry O. Knowing ‘how to go on’: structuration theory as an analytical prism in studies of intercultural engagement. J Ethn Migr Stud.
2016:1–19. doi: 10.1080/1369183X.2016.1148593.
Page 13/17
49. Schwandt DR, Szabla DB. Structuration theories and complex adaptive social systems: inroads to describing human interaction dynamics.
E:CO. 2013;15(4):1–20.
50. Cooney K. Fields, organizations, and agency - Toward a multilevel theory of institutionalization in action. Admin Soc. 2007;39(6):687–718.
doi: 10.1177/0095399707304116.
51. Doran F, Wrigley B, Lewis S. Exploring cultural safety with Nurse Academics. Research ndings suggest time to “step up”. Contemp Nurse.
2019;55(2-3):156–70. doi: 10.1080/10376178.2019.1640619.
52. Lutschini M. Engaging with holism in Australian Aboriginal health policy – a review. Aust New Zealand Health Policy. 2005;2(1):15. doi:
0.1186/1743-8462-2-15.
53. Butler TL, Anderson K, Garvey G, Cunningham J, Ratcliffe J, Tong A, et al. Aboriginal and Torres Strait Islander people's domains of
wellbeing: A comprehensive literature review. Soc Sci Med. 2019;233:138–57. doi: 10.1016/j.socscimed.2019.06.004.
54. Atkinson S, Ingham J, Cheshire M, Went S. Dening quality and quality improvement. Clin Med (Lond). 2010;10(6):537–9.
10.7861/clinmedicine.10-6-537
55. Gardiner-Garden J. Dening Aboriginality in Australia [Internet]. Canberra: Australian Parliamentary Library; 2015 [cited 2021 Dec 17].
Available from:
http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/Publications_Archive/CIB/cib0203/03Cib10.
5. Maddison S. Indigenous identity, 'authenticity' and the structural violence of settler colonialism. Identities-Glob Stud. 2013;20(3):288–303.
doi: 10.1080/1070289X.2013.806267.
57. Salmon M, Doery K, Dance P, Chapman J, Gilbert R, Williams R, et al. Dening the indenable: Descriptors of Aboriginal and Torres Strait
Islander Peoples’ cultures and their links to health and wellbeing. Canberra: Australian National University; 2018, 75 p.
5. Garneau AB, Pepin J. La sécurité culturelle: une analyse du concept. Recherche en Soins Inrmiers. 2012;(111):22–35. doi:
10.3917/rsi.111.0022
59. Foronda C, Baptiste DL, Reinholdt MM, Ousman K. Cultural humility: A concept analysis. J Transcult Nurs. 2016;27(3):210–7. doi:
10.1177/1043659615592677.
0. Roberts MLA, Schiavenato M. Othering in the nursing context: A concept analysis. Nurs Open. 2017;4(3):174–81. doi: 10.1002/nop2.82.
1. Henderson S, Horne M, Hills R, Kendall E. Cultural competence in healthcare in the community: A concept analysis. Health Soc Care Comm.
2018;26(4):590–603. doi: 10.1111/hsc.12556.
2. Cai D-Y. A concept analysis of cultural competence. International Journal of Nursing Sciences. 2016;3(3):268–73. doi:
10.1016/j.ijnss.2016.08.002.
3. Brooks LA, Manias E, Bloomer MJ. Culturally sensitive communication in healthcare: a concept analysis. Collegian. 2019. doi:
10.1016/j.colegn.2018.09.007.
4. Simmons SJ. Health: a concept analysis. Int J Nurs Stud Adv. 1989;26(2):155–61. doi: 10.1016/0020-7489(89)90031-X.
5. Nakata M. Disciplining the savages, savaging the disciplines. Canberra: Aboriginal Studies Press; 2007.
. McCabe P. An Australian indigenous common law right to participate in decision-making. Oxf Univ Commonw Law J. 2020;20(1). doi:
10.1080/14729342.2020.1739376.
7. Ferdinand A, Lambert M, Trad L, Pedrana L, Paradies Y, Kelaher M. Indigenous engagement in health: lessons from Brazil, Chile, Australia
and New Zealand. Int J Equity Health. 2020;19(1):1–12. doi: 10.1186/s12939-020-1149-1.
. Fernando T, Bennett B. Creating a Culturally Safe Space When Teaching Aboriginal Content in Social Work: A Scoping Review. Aust Soc
Work. 2019;72(1):47–61. doi: 10.1080/0312407X.2018.1518467.
9. Fleming T, Creedy DK, West R. Cultural safety continuing professional development for midwifery academics: An integrative literature
review. Women Birth. 2018. doi: 10.1016/j.wombi.2018.10.001.
70. Kurtz DLM, Janke R, Vinek J, Wells T, Hutchinson P, Froste A. Health Sciences cultural safety education in Australia, Canada, New Zealand,
and the United States: A literature review. Int J Med Educ. 2018;9:271–85. doi: 10.5116/ijme.5bc7.21e2.
71. Mackean T, Baum F, Fisher M, Friel S. A framework to assess cultural safety in Australian public policy. Health Promot Int. 2019. doi:
10.1093/heapro/daz011.
72. Dickson M. “My work? Well, I live it and breathe it”: The seamless connect between the professional and personal/community self in the
Aboriginal and Torres Strait Islander health sector. BMC Health Serv Res. 2020;20(1):972. doi: 10.1186/s12913-020-05804-3.
73. Gardiner-Garden J. Innovation without change? Commonwealth involvement in Aboriginal health policy [Internet]. Canberra: Australian
Parliamentary Library; 1994 [cited 2021 Dec 17]. Available from:
https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id:%22library/prspub/ODR10%22.
Page 14/17
74. Weaver SM. Australian Aboriginal Policy: Aboriginal Pressure Groups or Government Advisory Bodies? (Part 1). Oceania. 1983a:1–22.
https://www.jstor.org/stable/40330714
75. Weaver SM. Australian Aboriginal Policy: Aboriginal Pressure Groups or Government Advisory Bodies? (Part 2). Oceania. 1983b:1–22.
https://www.jstor.org/stable/40332274
7. Anderson I. The Truth about Indigenous Health Policy. Arena Magazine. 2001;56(Dec 2001-Jan 2002):32–7.
77. Anderson I. Aboriginal society and health: critical issues demand what from sociologists? Health Sociology Review. 2001;10(2):5–20.
7. Pozzebon M, Pinsonneault A. Challenges in conducting empirical work using structuration theory: Learning from IT research. Organ Stud.
2005;26(9):1353–76. doi: 10.1177/0170840605054621.
79. Guess TJ. The social construction of whiteness: Racism by intent, racism by consequence. Crit Sociol. 2006;32(4):649–73. doi:
10.1163/156916306779155199.
0. Giddens A. Action, Subjectivity, and the Constitution of Meaning. Social Research. 1986;53(3):529–45.
https://www.jstor.org/stable/40970430
1. Fleming T, Creedy DK, West R. The inuence of yarning circles: A cultural safety professional development program for midwives. Women
Birth. 2020;33:175–85. doi: 10.1016/j.wombi.2019.03.016.
2. Gainsford A, Robertson S. Yarning shares knowledge: Wiradyuri storytelling, cultural immersion and video reection. Law Teach.
2019;53(4):500–12. doi: 10.1080/03069400.2019.1667088.
3. Rigney L-I. Internationalization of an Indigenous Anticolonial Cultural Critique of Research Methodologies: A Guide to Indigenist Research
Methodology and Its Principles. Wicazo Sa Review. 1999;14(2):109–21. doi: 10.2307/1409555.
4. Rigney L-I. Indigenous Australian Views on Knowledge Production and Indigenist Research. In: Goduka NI, Kunnie JE, editors. Indigenous
Peoples' Wisdom and Power: Arming Our Knowledge Through Narratives: Ashgate; 2006, 32–49 p.
5. Eckermann A-K. Binan goonj: bridging cultures in aboriginal health. Armidale, NSW: University of New England Press, in association with
the Dept. of Aboriginal and Multicultural Studies, University of New England, and the Council of Remote Area Nurses of Australia; 1992. x,
244 p.
. Williams R. Revised Cultural Safety Paper-PHA [Internet]. Hobart: Public Health Association; 1998 [cited 2021 Dec 17). Available from:
https://www.utas.edu.au/__data/assets/pdf_le/0010/246943/RevisedCulturalSafetyPaper-pha.pdf.
7. Bin-Sallik M. Cultural Safety: Let's Name It! Aust J Indig Educ. 2003;32:21–8.
. Williams M. Ngaa-bi-nya Aboriginal and Torres Strait Islander program evaluation framework. Eval J Australas. 2018;18(1):6–20. doi:
10.1177/1035719x18760141.
9. Hunter K. Cultural safety or cultural appropriation? A nurse educator examines the use of Maori health models by non-Maori. N Z Nurs J.
2020;26:24–5.
90. Rasmussen M, Guo X, Wang Y, Lohmueller KE, Rasmussen S, Albrechtsen A, et al. An Aboriginal Australian genome reveals separate human
dispersals into Asia. Science. 2011;334(6052):94–8. doi: 10.1126/science.1211177.
91. YAITYA PURRUNA [Internet]. Adeladie: Faculty of Health and Medical Sciences; 2020 [cited 2020 Dec 24]. Available from:
https://health.adelaide.edu.au/engage/facilities-services/yaitya-purruna.
92. McLachlan S, Williams R. Waluwin - An integrated approach towards health and wellbeing in Western NSW, Australia. Int J Integr Care.
2016;16(6):A291. doi: 10.5334/ijic.2839.
93. Fleming K, Devanesen D. Health Policies and the Development of Aboriginal Self Management in the Northern Territory [Internet]. Darwin:
Northern Territory Department of Health; c1985 [cited 2021 17 Dec]. Available from:
https://digitallibrary.health.nt.gov.au/prodjspui/bitstream/10137/11372/1/Health%20Policies%20and%20AHWs.pdf.
94. Lechleitner Pangarta K. Research into Establishing an Aboriginal Men's Shed within the Central Australian Region. Int J Appl Psychoanal
Stud. 2018;15(2):114–8. doi: 10.1002/aps.1572.
95. Warringa Baiya Aboriginal Women's Legal Centre: Our Story [Internet]. Warringa Baiya Aboriginal Women's Legal Centre [Internet].
Marrickville: WBAWLC; 2019 [cited 2021 Jul 9]. Available from: https://www.wirringabaiya.org.au/2about-us.
9. Toombs M, Nasir B, Kisely S, Ranmuthugala G, Gill NS, Beccaria G, et al. Cultural validation of the structured clinical interview for diagnostic
and statistical manual of mental disorders in Indigenous Australians. Australas Psychiatry. 2019;27(4):362–365 doi:
10.1177/1039856219852289.
97. Kotz J, Marriott R, Reid C. The EPDS and Australian Indigenous women: A systematic review of the literature. Women Birth. 2020;
34(2):e128-e134. doi: 10.1016/j.wombi.2020.02.007.
9. Brown A, Mentha R, Howard M, Rowley K, Reilly R, Paquet C, et al. Men, hearts and minds: developing and piloting culturally specic
psychometric tools assessing psychosocial stress and depression in central Australian Aboriginal men. Soc Psychiatry Psychiatr
Epidemiol. 2016;51(2):211–23. doi: 10.1007/s00127-015-1100-8.
Page 15/17
99. Haswell MR, Wheeler T, Wargent R, Brownlie A, Tulip F, Baird M, et al. Validation and enhancement of Australian Aboriginal and Torres Strait
Islander psychiatric hospitalisation statistics through an Indigenous Mental Health Worker Register. Rural Remote Health. 2013;13(1):2002.
doi: 10.22605/RRH2002.
100. Gwynn JD, Hardy LL, Wiggers JH, Smith WT, D'Este CA, Turner N, et al. The validation of a self-report measure and physical activity of
Australian Aboriginal and Torres Strait Islander and non-Indigenous rural children. Aust N Z J Public Health. 2010;34 Suppl 1:S57-65. doi:
10.1111/j.1753-6405.2010.00555.x.
101. Thompson LJ, Duthie D. Towards Culturally Safe Social Policy Processes for Aboriginal Australians. Int J Interdiscip Soc Community Stud.
2016;11(4):47–62. doi: 10.18848/2324-7576/CGP/v11i04/47-62.
102. Ramsden I. Teaching cultural safety. New Zealand Nursing Journal. 1992;85(5):21–3.
103. Papps E, Ramsden I. Cultural Safety in Nursing: the New Zealand Experience. Int J Qual Health Care. 1996;8(5):491–7. doi:
10.1093/intqhc/8.5.491.
104. Smith T. A long way from home: Access to cancer care for rural Australians. Radiography. 2012;18(1):38–42. doi:
10.1016/j.radi.2011.10.041.
105. Newton BJ. Creating Cultural Safety as an Aboriginal Teacher in a Class of Non-Aboriginal University Students. Aust Soc Work.
2020;74(1):4–12. doi: 10.1080/0312407X.2020.1799422.
10. Parmenter J, Barnes R. Factors supporting indigenous employee retention in the Australian mining industry: A case study of the Pilbara
region. Extr Ind Soc. 2020;8(3):423–33. doi: 10.1016/j.exis.2020.11.009.
107. Gerlach AJ. A Critical Reection on the Concept of Cultural Safety. Can J Occup Ther. 2012;79(3):151–8. doi: 10.2182/cjot.2012.79.3.4.
10. Roberts J. Kawa Whakaruruhau - has its intent been lost? N Z Nurs J. 2020;25(11):14–5.
109. Ramsden I. Kawa whakaruruhau: cultural safety in nursing education in Aotearoa [Internet]. Wellington: Ministry of Health; c1990 [cited
2021 Dec 17]. Available from: https://www.moh.govt.nz/NoteBook/nbbooks.nsf/0/707224BC1D4953C14C2565D700190AD9?
opendocument.
110. Sheehan NW. Indigenous knowledge and respectful design: An evidence-based approach. Des Issues. 2011;27(4):68–80. doi:
https://www.jstor.org/stable/41261957.
111. Povey R, Trudgett M. When camp dogs run over maps: 'proper-way' research in an Aboriginal community in the north-east of Western
Australia. Aust Aborig Stud. 2019;(2):61–72.
112. Spencer VA. Formal recognition, freedom, and power: the case of Australia's First Nations. Polit Groups Identities. 2020;8(5):1083–93. doi:
10.1080/21565503.2020.1790397.
113. United Nations. United Nations Declaration on the Rights of Indigenous Peoples [Internet]. [New York: United Nations; c2008 [cited 2021 Dec
17]. Available from: https://www.un.org/development/desa/indigenouspeoples/declaration-on-the-rights-of-indigenous-peoples.html.
114. Jadhav S. What is cultural validity and why is it ignored? The case of expressed emotion research in South Asia. In: van der Geest S,
Tankink M, editors. Theory and action: essays for an anthropologist. Diemen: Uitgeverij AMB; 2009. pp.92–96.
115. Grant J, Parry Y, Guerin P. An investigation of culturally competent terminology in healthcare policy nds ambiguity and lack of denition.
Aust N Z J Public Health. 2013;37(3):250–6. doi: 10.1111/1753-6405.12067.
11. Pease B. From evidence-based practice to critical knowledge in post-positivist social work. In: Allan J, Briskmann, L, Pease, B, editors.
Critical social work: Theories and practices for a socially just world (2nd ed). Sydney: Allen & Unwin; 2009. pp.45–57.
117. Manton D, Williams M. Strengthening Indigenous Australian Perspectives in Allied Health Education: A Critical Reection. Int J Indig Health.
2021;16(1). doi: https://doi.org/10.32799/ijih.v16i1.33218.
11. The NSQHS Standards [internet]. Sydney: Australian Commission on Safety and Quality in Health Care; c2021 [cited 2021 Dec 16].
Available from: https://www.safetyandquality.gov.au/standards/nsqhs-standards.
119. Cusack L, Kinnear A, Ward K, Mohamed J, Butler A. Joint statement - Cultural safety: Nurses and midwives leading the way for safer
healthcare [Internet]. Melbourne: Nursing and Midwifery Board, AHPRA; c2018 [cited 2021 Dec 16]. Available from:
https://www.nursingmidwiferyboard.gov.au/news/2018-03-23-joint-statement.aspx.
120. Anderson I. Aboriginal Australians, governments and participation in health systems. In: Gardner H, Liamputtong, P, editors. Health, Social
Change and Communities. Melbourne: Oxford University Press; 2003. p.224–40.
121. Adams M. Close the Gap: Aboriginal community controlled health services. Med J Aust. 2009;190(10):593.
122. Johnstone M-J, Kanitsaki O. An exploration of the notion and nature of the construct of cultural safety and its applicability to the Australian
health care context. J Transcult Nurs. 2007;18(3):247–56. doi: https://doi.org/10.1177/1043659607301304.
123. Marriott R, Strobel NA, Kendall S, Bowen A, Eades AM, Landes JK, et al. Cultural security in the perinatal period for Indigenous women in
urban areas: a scoping review. Women Birth. 2019;32(5):412–426. doi: 10.1016/j.wombi.2019.06.012.
Page 16/17
124. National Centre for Cultural Competence, Australian Commission on Safety and Quality in Health Care. Literature Review on Factors
Affecting the Safety and Quality of Health Care for Aboriginal and Torres Strait Islander People. Sydney: The Centre; 2015, 67 p.
125. West R, Mills K, Rowland D, Creedy DK. Validation of the rst peoples cultural capability measurement tool with undergraduate health
students: A descriptive cohort study. Nurse Educ Today. 2018;64:166–71. doi: 10.1016/j.nedt.2018.02.022.
12. Downing R, Kowal E, Paradies Y. Indigenous cultural training for health workers in Australia. Int J Qual Health Care. 2011;23(3):247–57. doi:
10.1093/intqhc/mzr008.
127. Christidis R, Lock M, Walker T, Egan M, Browne J. Concerns and priorities of Aboriginal and Torres Strait Islander peoples regarding food
and nutrition: a systematic review of qualitative evidence. Int J Equity Health. 2021;7(20):220. doi: 10.1186/s12939-021-01551-x.
12. Maher BL, Guthrie J, Sturgiss EA, Cargo M, Lovett R. Dening collective capability in Australian evaluations that are conducted by, for and
with Indigenous peoples for health programmes, policies and services: a concept analysis protocol. BMJ Open. 2021;11(10):e055304. doi:
http://dx.doi.org/10.1136/bmjopen-2021-055304.
129. Have your say: Consultation on the denition of ‘cultural safety’? [Internet]. Melbourne: The Australian Health Practitioner Regulation
Agency; c2019 [cited 2021 Dec 16] Available from: https://www.ahpra.gov.au/News/2019-04-03-cultural-safety.aspx.
130. Australian Health Practitioner Regulation Agency. Report on ndings from the public consultation on the denition of ‘cultural safety’ for
use within the National Scheme: Consultation Report. Barton: The Agency; 2019, 5 p.
131. Australian Health Practitioner Regulation Agency. Submissions - consultation on the denition of cultural safety. Melbourne: The Agency;
2020, 165 p.
132. Australian Health Practitioner Regulation Agency. Survey report - consultation on the denition of cultural safety. Melbourne: The Agency;
2020, 35 p.
133. Fredericks BL, Adams K, Finlay SM, Fletcher G, Andy S, Briggs L, et al. Engaging the practice of yarning in action research. ALARj.
2011;17(2):7–19.
134. Buchanan J, Collard L, Palmer D. Ngapartji ngapartji ninti and koorliny karnya quoppa katitjin (Respectful and ethical research in central
Australia and the south west). Learning Communities-International Journal of Learning in Social Contexts Special Issue: Ethical
Relationships, Ethical Research in Aboriginal Contexts: Perspectives from Central Australia. 2018; 23(Nov):32-50.
135. Lock M, Walker T, Browne J. Promoting cultural rigour through critical appraisal tools in First Nations Peoples’ research. Aust N Z J Public
Health. 2021;45(3):210–211. doi: 10.1111/1753-6405.13097.
13. Hareld S, Pearson O, Morey K, Kite E, Canuto K, Glover K, et al. Assessing the quality of health research from an Indigenous perspective:
the Aboriginal and Torres Strait Islander quality appraisal tool. BMC Med Res Methodol. 2020;20(1):79. doi: 10.1186/s12874-020-00959-3.
137. Huria T, Palmer SC, Pitama S, Beckert L, Lacey C, Ewen S, et al. Consolidated criteria for strengthening reporting of health research involving
indigenous peoples: the CONSIDER statement. BMC Med Res Methodol. 2019;19(1):173. doi: 10.1186/s12874-019-0815-8.
13. Martin K. Ways of knowing, being and doing: A theoretical framework and methods for indigenous and indigenist re-search. J Aust Stud.
2003;27(76):203–14. doi: https://doi.org/10.1080/14443050309387838.
Table
Table 1 is available in the Supplemental Files section
Figures
Figure 1
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Transformation of structuration theory into a heuristic for analysis of cultural safety denitions
Figure 2
Cultural concept soup with thematic results
Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download.
S3Table1.docx
S4AuthorBiographies.docx
