Thank you for making the first Journal Club of this academic year a great success with insightful discussion generated from a representation of not only faculty, but also both student cohorts! Interesting discussion was generated on the topic of Cultural Competence and Safety Within Canadian Schools of Nursing. The chose article for discussion was:

Rowan, M. S., Rukholm, E., Bourque-Bearskin, L., Baker, C., Voyageur, E., & Robitaille, A. (2013). Cultural competence and cultural safety in Canadian schools of nursing: a mixed methods study. International journal of nursing education scholarship, 10, 43.

It can be downloaded here within UBC or here using EXProxy outside the University. A copy of the PowerPoint slides can be downloaded here.

The discussion began with a quick Poll Everywhere survey revealing that 60% of participants weren’t really sure they understood the difference between cultural competence and cultural safety. The concept of cultural competence was discussed as a continuum of cultural sensitivity and competence in providing care that is focused on being respectful of the clients culture and providing care that meets their cultural needs. Cultural safety appears less well-defined and involves a specific postmodern theoretical framework that considers the client on terms of an (oppressed) minority whose cultural needs have not been met by the healthcare system. This involves the notion that members of minorities (particularly aboriginal peoples) may feel threatened or “unsafe” within the dominant cultural healthcare system. See the attached handout of slides from the session for more details of both).

Cultural Competence (CC)

It was agreed in the group that cultural competence was more universally accepted and defined, and for educators much easier to incorporate into curriculum than cultural safety. Although the group felt cultural competence was a universal concept, several cases were brought to light that showed there were still issues with the cultural competence of nurses in Canada. A couple of cases of culturally inappropriate care with Sikh patients were discussed. Unfortunately, populations of Aboriginal and Muslim descent appear to bare the brunt of discrimination and biases with the Canadian health care system.

Cultural Safety (CS)

It was suggested that on a macro scale the principles of cultural safety can be used as an explanatory framework quite well, and represent an ideal to strive for in nursing care. However, the complexities of applying the principles on the day-to-day nursing care level in a public healthcare system were seen as more difficult. The following issues with the conceptual framework and practical complexities were further discussed:

• Does CS apply to all cultural groups, or just those minorities whose needs have been marginalized in some way?
• How does one cater to every minority group’s health care demands in a public funded multicultural system, and what determines which demands are met and which not, as the service cannot meet every cultural demand (e.g. a request for FGM)?
• As nurses we should always respect the personal and cultural choices and needs of individuals, but how do we provide a culturally safe environment when the cultural norms are not evidence-based practices available in the system?
• Is it really possible to make everyone feel culturally “safe” in a national multicultural health care system that is in itself a sub-culture?
• Does the current concept of cultural safety promote a divisive (oppressed/oppressor) view of people, and promote “victimary thinking?”
• How does the theory of culturally safety incorporate the dynamic nature of cultures?

Discussion of the Paper

Many felt that the article (or underlying theory of CS as it currently stands) did not adequately address some of these more challenging issues. The paper appeared to simply conflate theories of CC and CS without question, and failed to explore the subtle differences in any depth. Nevertheless, some members of the group also felt that CS could be practically applied in public health care to make all clients feel culturally safe, so there were different views within the group. The authors seemed to make an assumption that CS was universally well defined, understood and accepted in Canada, when this does not appear to be the case; as was evident even within our small discussion group.

It was suggested that the paper provided for a very general oversight, of the issues and was limited since it only sampled Anglophone populations in Canada. Although there were interesting findings, and many good points made about the need for CC training in the undergraduate curriculum, the paper did not really foster discussion on how to address the practical issues of providing CS care in practice, or provide any insight into the complexities that were brought up for reflection during our discussion.

It was suggested that these complex multi-factoral issues cannot be solved with simple fixes and changes in curricula that just expect change to happen in practice. The practice of CC should not just be limited to the healthcare workplace but also must take place in the whole community.

Reframing our thinking – a discussion arose that shifting focus from thinking that we ought to be doing something more in the nursing curriculum to promote CS, to actively thinking about how we can attend to achieving a more tolerant and less divisive society as a whole would be a good way forward. This was suggested as a more practical approach.

The need to make CC a normative in nursing practice was agreed by the whole group and it was felt this would ultimately lead to evolving conversations that can then focus on patient outcomes, that will shape policy, competencies, and standards of practice.

The following article was recommended by a member of faculty to those looking for more about cultural competence:

The unbearable whiteness of being (in nursing)

We hope to see you all in November for cookies and another great discussion! Check back here for the next article.

Powerpoint Presentation from the Journal Club: EKM Journal Club 5 Slides