Are cultural safety definitions culturally safe? A review of 42 cultural safety definitions in an Australian cultural concept soup

doi:10.21203/rs.3.rs-1179330/v1

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Are cultural safety definitions culturally safe? A review of 42 cultural safety definitions in an Australian cultural concept soup

https://doi.org/10.21203/rs.3.rs-1179330/v1

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Cultural safety is a keystone reform concept intended to improve First Nations Peoples’ health and wellbeing. Are definitions of cultural safety, in themselves, culturally safe? A purposive search of diverse sources in Australian identified 42 definitions 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 definitions that diminish (meddlesome modifications and discombobulating discourse), demean (developmentally dubious and validation vacillations), and disempower (professional prose, redundant reflexivity, and scholarly shenanigans) the cultural identity (problematic provenance and ostracised ontology) of First Nations Australians. We offer four guidelines for future definitional construction processes, and methodology and taxonomy for building consensus based of definitions 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.

Social Policy

Cultural Studies

Health Policy

cultural safety

First Nations Australians

structuration theory

definition

social policy

Indigenist

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 ‘reflexivity’ [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 definitions proliferate–Australian definitions of cultural safety are contained in Table 1 (Supporting information Table 1)–and our question is: Are cultural safety definitions 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 definition of cultural safety proffered. For example, while two cornerstone policies for health and for social policy [17, 18] emphasise cultural safety, a definition is absent—and practitioners need to search elsewhere for clarification.

Definitions as power points to frame meaning

Definitional clarity is important because definitions are ‘power points’ used to frame meaning. The embedded power of a cultural safety definition 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 definition (Table 1, Row 16) [19, 20]. Definitions are also powerful for professional accreditation. For example, the Australian Health Practitioner Regulation Agency (AHPRA) has developed a definition of cultural safety (Table 1, Row 25) that affects fifteen registered health professions and the professional standards of over 800,000 registered health practitioners [21]. However, there is little identification of how these professions will achieve cultural safety for accreditation beyond acknowledgment and recognition of the concept [22].

Further, cultural safety definitions 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 flagged 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 definition 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 definitions. 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 definitions is a worthy exercise because practitioners (i.e., employees or service providers in any social policy domain) use definitions to frame actions across their career pathways.

Definitional clarity is even more necessary when practitioners, in their search for cultural safety definitions, find 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 (and sometimes unknown) ingredients–may influence 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 definitions, Anthony Gidden’s Structuration Theory (ST) is useful and is defined as ‘the structuring of social relations across time and space in virtue of the duality of structure’ [47]. In terms of ST, cultural safety definitions occupy a modality ladle between agency and structure (Fig. 1). That is, definitions 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 definitions 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 influences attitudes and behaviours [51], which shows that definitions are vehicles of meaning for influencing attitudes.

However, an important caveat is that the face value of definitions obscures the intentions of their authors. In investigating the context of definitions (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 definitions 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 definitional development.

Are cultural safety definitions 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 definitions.

Definitional debates and concept analysis

Definitional 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 reflexivity about knowledge, discourse, power, and culture. This body of research is also deficient 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 specificity (Structuration Theory) and ensuring reflexivity 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 definition 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 field 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 signification, domination, and legitimation).

Fig. 1: Transformation of structuration theory into a heuristic for analysis of cultural safety definitions

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 influence social policy systems. They do so, according to Giddens, through routine social interactions that he describes through structuration concepts (identified in Fig. 1, and described below):

Structures – are rules and resources which actors draw upon and use in the communication of meaning:
1. signification—the ‘symbolic orders/modes of discourse’ [47] such as definitions of cultural safety positioned in wider discourse of cultural concepts,
2. domination – how codes of signification—such as racialisation [79]—are enacted using resources,
3. legitimation – the ‘social systems for normative regulation’ [79], such as reflected in legal institutions [47].
Modality - refers to, for example, writing and conversation as modalities of signification [80]:
1. interpretive scheme – as described above,
2. 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,
3. 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 reflected within the individual, to take part in and influence routines of daily life [47]:
1. communication and power – including communication of definitions, which are themselves power points of influence, and
2. 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 definitions of cultural safety were identified by searching different sources (December 2020 to July 2021, with supplemental searches afterwards to detect new definitions) using the keywords of ‘definition’ and cultural safety, and their Boolean operators. The webpage search string was ‘site:au definition “cultural safety” define “culturally safe”’, which returned hundreds of thousands of pages, of which the first 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 definitions extracted into a table where a taxonomical notation (Appendix 1, Table 1) was devised to allow cross-reference and comparison between definitions.

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 identified 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 infiltrate 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.

The extracted definitions 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 definitions 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.

Definitional diversity

Our search yielded 42 definitions of cultural safety (Table 1) in social policy about First Nations Australians. The definitional diversity appeared to begin with the first published definition of cultural safety, namely Eckermann’s 1992 book ‘Binan Goonj: Bridging Cultures in Aboriginal Health’, as reprinted in 1994 [85]. Hence, it is the first entry in Table 1 (Row 1). A taxonomy was created for tracking the source of definitions AKE-dCSaf-AU (Ann Katrin-Eckermann, definition of cultural safety, Australia). The second definition 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 modifications occur to Williams’ definition over the years, which is not the case for Eckermann’s definition. There are seven modifications to Williams’ definition (Table 1, Rows 3, 11, 15, 17, 19, 23, and 26). In our taxonomy, MBS-dCSaf(RW-dCSaf2)-AU, means that Maryann Bin-Sallik modified Robyn Williams’ definition. 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’ definition [87]. Other definitions of cultural safety (not Williams’ or Eckermann’s) were also modified by subsequent authors (Table 1, Rows 21, 24, 28, and 42).

The definitions also reflect 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 definitional diversity holds implications for ‘governance’ and ‘legitimation’ (Fig. 1) in the sense that definitions are vehicles of meaning for the governance actions driving organisational reforms that flow on to practitioner service delivery.

Developmentally dubious

Except for the AHPRA definitional development process (Table 1, Row 25), the processes for constructing definitions 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 definitions 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 (first level of Fig. 1) because community needs are not informing definitions and, thereby, guidance for practitioners to respond to community needs.

Problematic provenance

The cultural provenance of the definitions 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 definitions (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 definitions (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 ‘signification’ concept of structuration (Fig. 1) and social policy systems, because such ‘problematic provenance’ suggests the possibility of cultural appropriation [89] and signifies 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 definitions 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 definitions (Table 1) come with information about their methodologies of cultural validation: what was the instrument used to validate their process and their definitions? 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 reflect their cultural values.

Professional prose

Based on the individual (as opposed to organisational) authors the definitions 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 qualifications, and who were employed by mainstream organisations. Similarly, other definitions 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 qualifications.

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) definitions developed by individual authors avoid referencing their own professional standing and power, despite the philosophical rampart of ‘reflexivity’. Other definitions 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 influences practitioner attitudes and their practices.

Scholarly shenanigans

The definitions 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) definition but attribute it to an article by Ramsden (1992), which does not contain any definition [102], and this shenanigan also occurs in an article by Elvidge and colleagues [27]. The definition 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 ‘definition’ (Table 1, Row 41).

There is one incorrect citation of Williams’ (1999) definition 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 definition 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 definition (Table 1, Row 1) bears no resemblance to Williams’s definition (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 modifications

The definitions contain different ingredients (Table 1) with no explanation for their selection. In the health domain, these ‘meddlesome modifications’ of the concepts not only risk stultifying the cultural flavour of the soup, but also affect how definitions are interpreted. The modifications can be seen in the selection of key ingredients excised from each definition:

recognised, assured, reflects, you/your culture, language, customs, attitudes, beliefs, and preferred ways (AKE-dCSaf, Row 1)
determined, individuals, families, communities, practise, reflection, health practitioner, knowledge, skills, attitudes, behaviours, power differentials, safe, accessible, responsive, and racism (AHPRA-dCSaf, Row 25)
defined, health consumer, individual, experience, care, ability, access services, and raise concerns (AIHW-dCSaf, Row 27)
environment, diverse background, feels, valued, and accepted (LB-dCSaf, Row 29)

The meddlesome modifications hold implications for the ‘communication’ concept of structuration (Fig. 1) with the rationale that the selection of words (and who selects them) is significant for the communication of meaning to stakeholders and their organisations. Interestingly, the concepts of power (n=7), culture (n=12), reflexivity (n=6), and identity (n=20) are non-uniformly distributed and show selective word choices by authors.

Discombobulating discourse

The definitions 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 definition 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 definitional 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 definition.

Redundant reflexivity

All definitions (except the APHRA definition) occur without being reflexive to cultural diversity, power, and identity. The individual authors of organisational definitions (Table 1) are unknown, in that they do not identify themselves or their cultures, and in doing so demonstrate ‘redundant reflexivity’ (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 definitions 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 definitions (VACCA in Row 6, VACCHO in Row 8, CAPSC in Row 17, and SNAICC in Row 18). None of the whole-of-organisation definitions are accompanied by reflexive statements about the philosophical implications of infusion their different governance structures with cultural safety.

Overall, the organisational authorship processes, and the resulting cultural safety definitions, lack grounding in the frequent call for reflexivity so often made by authors of cultural safety definitions. This has implications for the ‘norm’ concept of structuration (Fig. 1, Level 2) because it signifies a convention for reflexivity to be an optional, rather than essential, feature of cultural safety.

Fig. 2: Cultural concept soup with thematic results

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 influence 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 definitions. The cultural risk in definitions 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 definitions of cultural safety. Although definitional diversity may be consistent with the philosophy of cultural safety, the increased availability of inconsistent information could be problematic in moving from definition 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 reflected in the problematic provenance of the definitions, 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-specific ontologies that need to be directing and informing policy and practice [110]. No stronger signification 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 definitions inflect 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-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 definitions.

Modality implications

Almost all definitions 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 definitions’ legitimacy for incorporation into stocks of knowledge and interpretive schemes. The partial exception is the AHPRA definition (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 definitions 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 influence the structure and agency of cultural safety definitions, 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 definition’ [115].

Furthermore, scientific rigour is lacking in the development of these definitions, 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 ramifies through each related concept of structuration. Practitioners, expected to practice evidence-based care [118], may not know to question the quality of cultural safety definitions, 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 definition they adopt/ascribe to ‘fits 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 definitions reflect the cultural voices of First Nations Australians. The risk is that the 42 definitions and their discombobulating discourse influences practitioners’ interpretive schemes and erode confidence in their interactions with First Nations clients.

The implication of definitional 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 definitions. Reliable guidance is, moreover, complicated by the shenanigans of scholars, their meddlesome modifications, and their redundant reflexivity about the power of words.

The selection of words and who selects them are significant 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 definition (NMFBA-dCSaf, Table 1, Row 24) but not in another definition (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 defined 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 reflect on the balance of cultural identity, profession power, and community voices evident (or not) in definitions.

Several definitions of cultural safety show that the assessment of a safe service needs to be defined 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 definitions of cultural safety, not only at the point of assessing the outcomes of services. The absence of cultural validation in definitions 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.

Definitions enable cultural risk

Based on this analysis of publicly available online documents, Australian cultural safety definitions – on face value – are actually culturally unsafe. The themes show that cultural risk is embedded in cultural safety definitions that diminish (meddlesome modifications and discombobulating discourse), demean (developmentally dubious and validation vacillations), and disempower (professional prose, redundant reflexivity, and scholarly shenanigans) the cultural identity (problematic provenance and ostracised ontology) of First Nations Australians.

Clarifying the cultural concept soup

Clarification 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 conflated 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 definitions that inform training program design.

Reflective guidelines

We serve-up four guidelines for the development and use of cultural safety definitions, namely to reflect on language power, to describe the process, to epitomise First Nations Australians’ community voices, and to ensure cultural rigour.

Reflect 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].
Describe the process: Clearly explain the steps used in definition development, as recently outlined [128]. The AHPRA process is an example of transparency and accountability through publications [129-132].
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].
Ensure cultural rigour: The cultural rigour [135] of the definitional 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 definitions 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 find even more Australian definitions. While Structuration Theory has provided a new perspective from which to view cultural safety definitions, it is a western sociological concept not developed with or by colonised peoples. Caution must also be exercised to avoid over-ascribing the significance of definitions as deterministic of human intentions.

This study revealed ten cultural risks based on an analysis of 42 definitions of Australian cultural safety gathered from an online search of diverse sources. Our findings 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 definitional 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.

Acknowledgements

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.

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Are cultural safety definitions culturally safe? A review of 42 cultural safety definitions in an Australian cultural concept soup

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Abstract

Figures

Introduction

Definitions as power points to frame meaning

Power of meaning dissolved in a cultural concept soup

Interpretive schemes as ladle between structure and agency

Methodology

Definitional debates and concept analysis

Theoretical orientation

Data collection

Thematic development

Results

Definitional diversity

Developmentally dubious

Problematic provenance

Ostracised ontology

Validation vacillations

Professional prose

Scholarly shenanigans

Meddlesome modifications

Discombobulating discourse

Redundant reflexivity

Discussion

Structural implications

Modality implications

Agency implications

Definitions enable cultural risk

Clarifying the cultural concept soup

Reflective guidelines

Limitations

Conclusion

Declarations

References

table

Supplementary Files

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