Why we need to abandon cultural competency

Cultural competency and cultural safety are often confused as being about the same thing: the efforts by health practitioners and their organisations to lift the health outcomes and experience for Māori and indigenous peoples elsewhere.

The terms have been with us for more than 40 years. However the gaps in healthcare experience and outcomes persist. If you are Māori you will live 7.3 years fewer than non-Māori. Though Māori experience a high level of need for healthcare, they have less access to that care, and whether it is at a primary and preventative level or at a hospital, the quality of that healthcare tends to be poorer.

When adjusted for need, Māori patients will experience lower levels of investigations, interventions and receive fewer prescriptions than non-Māori. Research shows that Māori health consumers are far less likely to receive consistent and understandable answers to important questions they ask of health professionals, and so are significantly less likely to get understandable explanations of their health issues. Māori are significantly more likely to feel that their doctor or nurse is not listening.

Our extensive literature review points to unintended consequences from narrow and limited definitions of cultural competency and we propose that for real, lasting change for Māori, health practitioners and their organisations need to focus less on ‘cultural competency’ and instead move to act on a clear and shared definition of ‘cultural safety’.

Confusing, ineffectual

As a concept, cultural competency has existed since the 1980s, and has had a raft of interpretations across different countries and, often, within countries. The range of terminology will be familiar: cultural awareness, cultural sensitivity, cultural respect, transcultural effectiveness, and cultural proficiency, to name some examples.

A 1989 American definition was: “Cultural competence is a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals to enable that system, agency, or those professionals to work effectively in cross-cultural situations.”

But as terminology and interpretations grew rapidly in the 1990s, so too did confusion in the health sector. Without common, shared understanding of what cultural competency represents, what a person or an organisation might do to achieve it enters a grey zone that makes real change unlikely.

As well as being ineffectual due to confusion, the often narrow definition of cultural competency by health organisations actually undermines work to reduce health inequities.

This is because organisations have tended to cast cultural competency as an individual rather than organisational process. It is for individual health staff to gain cultural knowledge. As academics have noted: “Achieving cultural competence is often viewed as a static outcome. One is ‘competent’ in interacting with patients from diverse backgrounds in much the same way as one is competent in performing a physical exam or reading an EKG. Cultural competency is not an abdominal exam. It is not a static requirement to be checked off some list…”

The consequence of this narrow approach is the ‘othering’ of patients who are not part of the dominant culture. This leads to over-simplified understandings based on cultural stereotypes but also the tendency to group indigenous people into a collective ‘they’. Meanwhile those patients at the receiving end of ‘othering’ report that they experience exclusion, fewer opportunities to explore health care and questions, and marginalisation.

While often linked with cultural competency, the origins of cultural safety are entirely different. Cultural safety was first proposed in New Zealand by Dr Irihapeti Ramsden and Māori nurses in the 1990s. The Nursing Council made cultural safety a formal part of nursing and midwifery education, defining it as “A focus for the delivery of quality care about power relationships and patients’ rights.”

This concept rejects the notion that health providers should focus on learning cultural customs of ethnic groups. Instead cultural safety seeks to achieve better care through becoming actively conscious of difference, decolonisation, and power relationships and by putting in place a reflective practice where the patient decides whether their clinical encounter is safe.

The shift is fundamental. Cultural competency, under its varied definitions, focuses on the culture of the ‘exotic, other patient’. Cultural safety, approached critically, gives the opportunity to reflect on the culture of the clinician and health setting. For the clinician it involves self-reflection and a stepping back to understand their assumptions, biases and values, and consider imbalances in power. The aim is to consider ways to transfer power to enable patient-led change and better health outcomes.

It will be no surprise that cultural safety as a formal practice will be confronting for health professionals and institutions. However in the face of continuing, persistent health inequities for Māori, it is a transformation that urgently needs to happen.