This blog refers to a recent article ‘Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition‘
Competence versus Safety, says who?
The cultural training industry is making big $$$$ charging for cultural competence and cultural safety programs. Basically, the difference between competence and safety is “I’ve learned about your culture and can use that knowledge to improve your health towards what it should be” (competence) versus “I’ve reflected on my culture and realise how it is harmful to your culture and I will change my practise to what you think it should be” (safety). Underlying the enormous array of cultural training programs designed to teach non-First Nations peoples these cultural differences is the problem of professional dominance and citizen voice.
The research of Curtis et al. (2019) focusses solely on the assessment of literature and does not seek the perspectives of patients, consumers or citizens. The research is Māori determined and controlled, though by medical health professionals, which signals a dangerous philosophical movement – the First Nations health professional as the voice of Indigenous cultures, peoples, community and citizens.
Professionals versus Citizens
There used to be a strong movement in Australia of consumer and citizen engagement in healthcare. The most obvious example is the development of Aboriginal community controlled organisations in the early 1970s because of racist health professionals embedded in a racist culture. First Nations citizens sought control in decisions about healthcare. Now, there are many more First Nations professionals and associations and networks and organisations. In my analysis of the policy and research literature about cultural safety in Australia, the First Nations citizen voice has almost disappeared to be replaced with voices of First Nations professionals.
A Dangerous Standpoint – First Nations Professional Citizen
There is an argument that “I’m a First Nations professional and speak for culture and for community”. This research is an example as is the blog post. It’s a dangerous position to take because expert non-First Nation professionals are implicated in First Nations peoples’ disadvantages: is replacing ‘non-First Nation’ with ‘First Nations’ as experts and professionals going to reduce First Nations peoples’ disadvantages? Certainly, First Nations professional associations want more lawyers, doctors, nurses, midwives, psychologists and teachers. But they have acquired privileges – expert training, education, incomes, positions of influence – privileges over consumers and citizens.
Critical Reflexivity Empowers Professionals
The position in the blog and research by Curtis and colleagues can be read thus, “As a critically reflective professional my service will be culturally safe (especially when I pay for expensive cultural training)”. This is the position I see Australian discourse on cultural safety moving, with the emphasis on loads of expensive cultural safety courses.
I’ve tried to review cultural safety training courses, but they are locked behind corporate confidentiality walls and, as a First Nations Australian citizen, I cannot see what those courses are saying about me – a dis-empowering position. In comparison, I haven’t found any consumer or community development courses about cultural safety where the emphasis is on community empowerment. Thus, the power and privilege of the professional class is maintained.
Where is Citizen Consumer Power?
In research and policy, I struggle to see citizen and consumer voices and structures set-up to privilege those voices. For example, of all the First Nations professional associations in Australia that I’ve researched, none have a consumer, citizen or community engagement policy or strategy. Worse still, patient surveys and cultural self-assessment tools (tick the box) approaches as a proxy for cultural safety are gaining in prominence. Curtis criticises cultural competence as a ‘tick the box’ approach to cultural knowledge. Tokenism comes to mind, as well as diminishing and demeaning.
An Uncomfortable Reality
As a young policy officer in the late 1990, it was made clear to me that (an unwritten) part my employment contract was the expectation that because I am Aboriginal Australian that I could explain about the holistic concept of Aboriginal health and its relevance for every policy topic that came across my desk. The proposition was “Aboriginal people believe in the holistic concept of health and your Aboriginal so use your knowledge to make our policies better”. I hadn’t heard about the holistic concept of health until I became a professional. Not in my youth, in my family, in my community, did anyone sit be done and say “son, this holistic concept of health means…” Never any community development courses about holistic health. Getting food, shelter, being safe and staying away from policy and authority, now they were real concerns.
Professionals and community inhabit different worlds (with ‘citizen’ being the overlap) and as a First Nations researcher with privileged knowledge and expertise, I work hard to privilege community and citizen voice in my research practise. I am highly critical of most research about cultural safety in Australia because the research processes are structured to disempower citizens, it’s always the professional academic developing the research idea, conducting the literature review and formulating the methodology, then consultation with the community (and that’s about the only detail written about). Community first is always the mantra but not the practise.
Community Relational Processes Disrespected
Ramsden’s work in New Zealand was the same, there was never a community validation process undertaken to test if her view was broadly accepted. The same with Williams’ Australian re-definition of cultural safety. The same with Leininger’s work on trans-cultural care, who determined and drove the entire cross-cultural care movement without any process of community validation (that I know of). The same with Cross’s work on cultural competence in the United States, whose seminal publication shows professional dominance in that cultural reform agenda.
Privileged professional individuals driving individual reforms without reflecting on their profession power and privilege, and without deep and meaningful community engagement processes.
Yes, it’s all too familiar! The same phenomenon occurs when non-First Nations health professionals speak about community needs but the most sophisticated mechanism, they have is a ‘community reference group’. Of the mainstream health professional associations that I’ve reviewed, none have a community engagement strategy. The belief that the health professional speaks for community and citizen needs is strong in Australia. I see this replicated by First Nations professionals and in the research of Curtis et al. (2019).
In Australia, First Nations professionals need to show how to decolonise research by putting community relational processes first and by actively dis-empowering their professional dominance in the research process.
Attribution: Lock, M.J. (2020, March 13). Is the First Nations Professional Class a threat to Culturally Safe Citizens? Committix Blog. https://committix.com/2020/03/13/is-the-first-nations-professional-class-a-threat-to-culturally-safe-citizens?