Dr Lynne McKinlay and Dr Najeeb Rahman, both Senior Medical Educator with Cognitive Institute, explore how healthcare leaders can establish a culturally safe environment for patients, their families, and health workers, and how barriers can be removed to the provision of inclusive care.

‘The ache for home lives in all of us, the safe place where we can go as we are and not be questioned.’

Maya Angelou (1928-2014), the American poet, memoirist, and civil rights activist, wrote these words in 1986 and they give us a sense of what cultural safety is really about.  Some people have lots of ‘safe places’, but for others, these ‘safe places’ are few and far between. Frequent exposure to ‘unsafe places’ or places where your identity or culture are questioned, challenged, or demeaned, can result in a range of health issues. Culture dictates how we define health concerns, whether we identify problems and how we frame those problems, whether we seek help or not, the solutions we seek, and how we define success. Culture and cultural safety or its lack are therefore important determinants of health. Both healthcare leaders and clinicians have a role to play in establishing culturally safe environments for patients, their families, and healthcare workers. Doing so is crucial to the provision of safe and equitable healthcare.

Reducing health inequalities is a matter of both fairness and social justice. As argued by the Institute of Health Equity post pandemic, the need to ‘Build Back Fairer’, should be our mantra, not just ‘Build Back Better’(1). The levels of social, environmental and economic inequality in society are damaging health and wellbeing. A stark example of this is highlighted by data released by the Kings Fund in September 2021, in relation to NHS surgical waiting lists (2). An existing national problem, exacerbated by the pandemic, this analysis showed that those living in the most deprived areas are nearly twice as likely to wait more than a year for treatment compared to those living in the least deprived areas.

A critical factor for overcoming health inequities is cultural safety. So, what is the link between cultural safety and patient outcomes or health system performance metrics such as long waiting lists? A substantial volume of literature has been written on the subject.

Equal treatment does not provide equal outcomes. The literature is compelling in identifying that cultural safety is an important factor in overcoming health inequities.

An article published by Powell in the BMJ in 2022 highlighted important examples of where the care provided has been different due to structural biases, such as the under detection of hypoxaemia by pulse oximetry, or the underdiagnosis of melanomas by cancer software, because of the skin pigmentation of Black patients(3). Both situations were as a result of White patients being used as the default group when these medical devices and their diagnostic algorithms were designed and tested.

Many researchers and commentators agree that overt prejudice is rarely the cause of disparities in healthcare offered, and clinicians generally see themselves as socially conscious people, who would not allow direct prejudice to compromise their care for patients. A 2003 report by the Institute of Medicine does however suggest that among the multiple factors that influence clinicians’ decisions, bias and stereotyping may play a role, resulting in ‘unequal treatment’, and hence unequal outcome(4). 

While clinicians want to do their best for all patients, beliefs about patients may result in the unconscious and automatic projection of stereotype when making clinical decisions. Clinicians are taught and learn using pattern recognition, which includes understanding the risks present in population segments for certain diseases. However, that stereotyping can limit history-taking and lead to diagnostic error if the clinician does not differentiate the individual patient in need of treatment from the well-learned mental image of the ‘typical patient’. For example, diagnoses such as obstructive sleep apnoea or silicosis may be delayed or missed in women due to the conditions being thought of, or taught as, stereotypically affecting men (5). Unconscious bias may also lead to a concept termed moral rationing, where clinicians make decisions to offer or withhold care based on their perception of patient qualities, such as their likelihood of compliance or social support network(6).

Recognising that we all have unconscious biases is the start of delivering culturally safe care.

Cultural safety goes beyond cultural awareness, cultural sensitivity and cultural competency, and requires self-knowledge of our own culture through introspection and reflection, to recognise, address and manage unconscious bias. Initially conceptualised, defined and developed by Dr Irihapeti Ramsden and Māori nurses in New Zealand in the late 1980s(7) we now understand cultural safety to be applicable to a wide range of settings from education to policing, and its relevance well beyond delivering culturally safe healthcare to First Nations or ethnically diverse communities. A key factor lies in balancing the notion of power, with the focus of the delivery of quality care through changes in thinking about power relationships and patient rights.

Without cultural safety, the healthcare environment is at risk, with the potential for poorer patient outcomes, unfair care, workplace shortages and losses, all of which may result in financial, reputational and possible legal impacts.

While the Equality Act 2010 protects against unlawful discrimination against those with a recognised protected characteristic (age, disability, gender reassignment, pregnancy and maternity, race, religion or belief, sex and sexual orientation) there is more for healthcare leaders to consider when assessing how biases can impact the care we offer. An example of those who fall outside of the protected characteristics but may nevertheless be subject to clinician bias, knowingly or unconsciously, is whether a single woman is offered access to assisted reproductive technology or a procedure resulting in sterilisation(8). Health inequity has been identified in numerous studies across all surgical specialties demonstrating pervasive racial and ethnic surgical disparities and exhibiting the need for culturally competent surgical care(9).

If being culturally unsafe implies a place where actions diminish, demean or disempower the cultural identity and wellbeing of an individual, with all its associated consequences on health and outcomes, then then healthcare leaders must work to develop and implement system-wide improvements, where patients not only feel safe but can thrive.

Healthcare providers can provide avenues to improve the likelihood of a patient feeling safe within their facilities. A 2022 study by Seale showed that patients who received most of their care from clinicians who spoke the patient’s primary language had better in-hospital outcomes, shorter stays in hospital, lower risk of adverse events during hospital admission, and their risk of in-hospital death was reduced by half(10).

Having a culturally diverse workforce appears to be critical for improving outcomes for patients. Recent publications emphasise the benefits of patient-clinician concordance – when patients see themselves as similar to their clinicians in personal beliefs, values and communication – on clinical care outcomes for underrepresented minorities. The research suggests patient-clinician concordance can minimise the impact of biases, boost communication, and increase trust. A 2020 study published by Greenwood and colleagues examined concordance in childbirth, noted as a setting where racial disparity is particularly severe. The results examined 1.8 million hospital births in the state of Florida, USA, between 1992 and 2015. The data suggests that newborn-clinician racial concordance is associated with significant improvement in mortality for Black babies, halving the risk(11).

Having an Equality, Diversity and Inclusion (EDI) policy, while important, does not mean that your organisation is inclusive, or that your workplace is culturally safe. From a health worker standpoint, inclusion and the feeling of belonging are fundamental to wellbeing, with social connectedness being one of the most important resilience factors. To explore the case in point, NHS employment statistics note a diverse workforce, with ethnic minorities over-represented overall in comparison with the general population. However, marked inequalities persist in type and grade of employment, reflected in pay bands, representation among senior staff and representation on NHS Trust boards(12). It is reported that doctors from ethnic minorities are twice as likely to be referred to the GMC by their employers for fitness to practice concerns than White doctors, and the referral rate for doctors qualifying outside of the UK is three times higher than for those who qualified in the UK. Bullying, harassment and discrimination continue to be reported at worryingly high rates in our workplaces(13). A recent analysis of recruitment decisions across 12 NHS trusts found that White doctors applying for medical posts in London are six times more likely to be offered a job than Black applicants, and that White doctors are four times more likely to be successful than Asian candidates or candidates from a mixed ethnic background(14).

We have, and need, a diverse workforce. Being inclusive and culturally safe may give you the edge over other organisations and help in retaining staff for longer. Discrimination and culturally unsafe workplaces are associated with adversities such as greater depression, anxiety, somatic symptoms, low job satisfaction and sickness absence(15). The seriousness of these issues and the importance of promoting and protecting wellbeing at work is underlined by the world’s first International standard to address psychosocial health at work being published in June 2021 (16). The standard provides guidance on managing psychological health and safety risks at work, recognising that employers have a responsibility to protect both the physical and psychological health of their workforce.

Given that advancing cultural safety is a critical component to ensuring safer healthcare settings, the challenge remains in the tools and approaches which can be utilised to catalyse change. The King’s Fund proposes a framework of the three A’s: Awareness, Action and Advocacy, in its approach to addressing health inequalities(17). It is an impactful conceptual framework which can be used for cultural safety improvements.  For example, an organisation can support awareness by providing education about the social determinants of health and health inequity and providing training in cultural safety. Action comprises fostering a culture of two-way learning, where we ask rather than assume, in parallel with building capacity for reflection and taking a continuous quality improvement approach. Advocacy is driven through inclusion and diversity in the workplace, in leadership roles, with consumer representation and input, and promoting culturally safe practices through the modification of clinical environments(18-21). Including a fourth ‘A’ representing Allyship would further acknowledge the need for, skills and a commitment to speaking up when we become aware of racism, discrimination or bias in healthcare, either relating to patient care or to the psychosocial safety of our workforce(22).

Cultural safety requires a commitment by healthcare workers and healthcare leaders to reflect on how their own views and biases impact on their interactions with patients and colleagues, and the care provided to patients. We need to measure what matters, then build in accountability to ensure reflection, learning and continuous improvement to create and maintain change over an extended time.

Cognitive Institute works with healthcare providers to navigate the complexity of modern healthcare in order to reduce risk and improve patient and staff safety.  Highlighting critical aspects of healthcare improvement, such as cultural safety, is part of our mission to share our knowledge and insights and equip leaders with non-technical skills to practise safe, reliable and kind healthcare.

This article was originally published by Healthcare Markets and is republished here with permission.

Note: Black and White when describing race are capitalised in accordance with the APA style and grammar guidelines for bias-free language.
Racial and ethnic identity (apa.org)


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