Cultural safety and the medical profession in Aotearoa New Zealand: a training framework and the pursuit of Māori health equity

This paper traces the origin of cultural competence and cultural safety in teaching programmes in New Zealand medical schools, and their journey into the standards of the Medical Council of New Zealand (MCNZ) and then into the training programmes of the Council of Medical Colleges (CMC). Beginning with cultural safety within the nursing profession in the early 1990s, we describe the contemporaneous pathways that medical cultural competence teaching programmes took in their own effort to improve health service delivery for Māori.

Longstanding inequitable Māori health outcomes saw the MCNZ introduce a cultural competency statement for medical practitioners in 2006. In 2016 the MCNZ and Te ORA (Te Ohu Rata o Aotearoa, the Māori Medical Practitioners Association) sought to review that work and held two national workshops and a programme of research. These activities spearheaded the 2019 development of a statement on cultural safety. Later collaboration with the CMC investigated cultural safety training in vocational training colleges and, finding it lacking, a cultural safety training framework for specialist vocational training and the re-accreditation of specialist medical practitioners was developed.

The cultural safety training programme is herein described in detail. We highlight the context of a robust cultural safety training programme alongside other learnings, with its focus on self-reflective practice, power relationships and its potential to contribute to a shift in the many “difficult to change” Māori health inequities. We conclude that Māori health requires a body of teaching that stands apart as an Indigenous body of knowledge including knowledge, skills and reflective aspects of practice designed to promote a culturally safe medical practice and culturally safe places to train and work.

Background

Cultural safety has its origins in the late 1980s, when Dr Irihapeti Ramsden, a prominent nurse educator, introduced a programme called He Kawa Whakaruruhau.¹ The intention was to improve health outcomes for Māori and other marginalised groups by encouraging nurses to develop a reflective “critical consciousness” practice around patient engagement—looking critically at their own attitudes, assumptions, stereotypes and prejudices (including racism) at work. It sought to transform power relationships in the clinical encounter and champion patient rights to determine what culturally safe care is. Cultural safety was to be applied across ethnicity, gender, age, ability, sexuality and religious groups. It has subsequently become an integral part of nursing training. At the time, however, Ramsden noted “outraged responses on the part of some students and some teachers and the notion that students were being ‘socially engineered’ by Indigenous interest groups.”²

The medical profession’s adoption of training in culturally safe practice involved a more conservative pathway. The introduction of teaching around Māori health began in the 1970s; for example, in the Auckland medical training programme, there were experiential “marae trips” as part of the Behavioural Science course. Later, more formal Māori health teaching began when the medical schools appointed lecturers in Māori Health—Auckland in 1987 and Otago in 1989. The teaching involved imparting information (a knowledge base) about Māori history and culture to contextualise the presentation of a Māori patient. It was, at the time, called “cultural sensitivity”. It came to include the development of culturally appropriate behaviours (a skills base); for instance, the correct pronunciation of Māori names and appropriate traversing of Māori rituals of exchange and other customary practices. In both medical schools, this became an increasingly more significant teaching component, and more latterly, a comprehensive public health approach to the health of Māori populations was adopted. The “self-reflective” critical consciousness-based cultural safety teaching developed in medical schools in the 2010s. The knowledge, the skills and the self-reflective practices are mostly now all taught in medical schools under the label of Hauora Māori.

The notion that cultural knowledge and cultural skills constituted a distinct health-related competency for all medical practitioners (around diverse groups of patients) was introduced into the wider medical environment in the Health Practitioners Competence Assurance Act 2003. Section 4; Part 6(b) (iv) referred to “… setting standards of clinical competence, cultural competence and ethical conduct.” In 2006, the MCNZ issued the Statement on cultural competence.³ Another document published at the same time, Best health outcomes for Māori: practice implications, outlined what cultural competence meant in relation to Māori.⁴ Subsequently, larger medical colleges began to develop teaching programmes within their training and Continuing Professional Development (CPD) programmes.

In 2015, the MCNZ sought to review their 2006 cultural competence statement and to explore its effect on Māori health equity and participation by Māori in health services. This process started a collaboration with Te ORA in developing the 2016 Cultural competence, participation and health equity symposium. The outcome was a joint advisory and governance group on cultural competence and equity, with a programme of research on cultural competence in New Zealand medical practice.

A second Cultural competence, participation and health equity symposium in June 2019 had an extensive programme that highlighted the health effects of racism and colonisation, two medical colleges’ initiatives around equity-focussed cultural competency and two engagement models for cultural competence. Finally, a comprehensive literature review of cultural competence and cultural safety was presented, which noted mixed and unclear definitions of cultural competence and cultural safety and the potential for cultural competency alone to actually do harm.⁵ A new definition of cultural safety was proposed, and the authors concluded that medical practice based on cultural safety, with its emphasis on reflective practice around power, privilege and bias, was better suited to address health inequities than the skills-based cultural competency model. Embedding cultural safety training across all medical colleges was recommended. In particular, the authors asserted that we should systematically apply cultural safety within a healthcare organisational context as well as the individual health provider–patient interface. This workpiece was the basis of the MCNZ issuing the Statement on cultural safety⁶ in October 2019 to replace the 2006 Statement on cultural competence. In a fashion similar to the 2006 statement, a document called He Ara Hauora Māori: A pathway to Māori health equity was also published.⁷

The MCNZ commissioned Baseline Data Capture: Cultural Safety, Partnership and Health Equity Initiatives, which published, in October 2020,⁸ the baseline data required to measure the progress of change. This document detailed the need to acknowledge the disempowering role that structural barriers and systemic racism within health systems play, alongside the privilege that advantages Pākehā patients, in inequitable health outcomes. It also recognised the additional cultural loading on doctors who identify as Māori. Workforce recruitment strategies of Māori staff were also mooted, Māori representation in health governance was recommended, and the collection and use of robust ethnicity data for equity monitoring was highlighted—all to foster thinking and focus on self-reflection and culturally safe practice.

Around the same time, the CMC enlisted Te ORA to evaluate the equity implications of the Choosing Wisely campaign, an international programme seeking to reduce unnecessary medical care by the facilitation of shared decision-making between practitioner and patient. Feedback from Māori health consumers and Māori health providers highlighted that enabling shared decision-making for Māori in a healthcare context would require promotion of cultural safety, patient-centred care, quality improvement and equity-based training.⁹

A collaboration between the CMC, Te ORA and the research group Allen + Clarke asked what cultural safety and health equity training was being undertaken by the colleges, and how Māori fellows and trainees experienced their medical specialty training. The Cultural safety within vocational medical training¹⁰ research project involved the repeat of an online survey of medical colleges (which had been conducted by Te ORA in 2017), and the pursuit of supplementary qualitative data from Māori fellows and trainees was sought by the focus group. The findings illustrated that while cultural competence training in the larger colleges was often adequate, cultural safety training was not well developed, and this was further complicated by varying definitions of cultural safety. It showed that there were few Māori in the training programmes, few Te Tiriti o Waitangi statements in college documents and little, if any, Māori participation in governance. It also noted that the cultural safety of the training environment for Māori trainees was supervisor-dependent rather than college-dependent—in other words, they had no cultural safety standards for their trainer/supervisors. Māori trainees said they felt culturally unsafe and that their main support was their Māori peers. Subsequently, it was decided by the CMC and Te ORA that the development of a formal cultural safety training framework should be embarked on to support the formal development of cultural safety training in colleges.

The Literature and Environmental Scan of Cultural Safety in Medical Training¹¹ research aimed to identify and assess cultural safety training programmes in Aotearoa New Zealand medical training and elsewhere, and to determine to what extent Aotearoa New Zealand initiatives focussed on “cultural safety” versus “cultural competence”. It reviewed 44 journal articles or reports and added interviews with representatives from a sample of six small and large Aotearoa New Zealand and Australasian medical colleges. The findings identified: that teaching consisted, for the most part, of health knowledge and cultural competency relevant only to Māori; that training programmes utilised a variety of teaching methods and had no consistent assessment procedures; that the content of the training was relatively brief and was not well embedded in the overall training programme; and that there was no evidence in the literature that current cultural competence or cultural safety programmes impacted on health outcomes, particularly equitable outcomes. It concluded that significant organisational commitment in the form of position statements, action plans, resourcing and staff are needed if cultural safety training is to be embedded in training programmes.

The cultural safety training plan

The development of the Cultural Safety Training Plan for Vocational Medicine in Aotearoa¹² (the Plan) was intended to help colleges successfully add an effective cultural safety component of training to their existing (noting nomenclature variations) Hauora Māori or cultural competence training programmes. The Plan starts by briefly describing the journey of Hauora Māori, cultural competence and cultural safety training in Aotearoa New Zealand. It reiterates the importance of cultural safety in the pursuit of health equity for Māori. Cultural safety is then presented within a broad conceptual framework, defining the proficiencies of the culturally safe practitioner and providing a teaching and assessment framework to support practitioners’ development of cultural safety skills. Finally, it includes a simple assessment mechanism to self-monitor progress.

A proposed conceptual framework on which to build the Plan poses the attainment of “optimal health for Māori” as the focal point of the model (Figure 1). Such “optimal health” is embedded in the three “domains” of Hauora Māori, cultural competence and cultural safety. These are posited as essential items that contribute to optimal health.

View Figure 1–4, Table 1–2.

These three domains are then defined, and the performance outcomes for the medical practitioner, if they should acquire these, are stated (Figure 2). We note here, recognising that these three components are inextricably related, that in our framework Hauora Māori refers to a Māori health knowledge base, but that in medical school training the Hauora Māori teaching programme has all three components in a single programme. There are also wider trainings pertinent to more diverse ethnic, religious, gender and ability groups in which other equitable outcomes are sought.

In turn, these three domains sit nested within a milieu of varied health system “concepts underpinning optimal health for Māori” (Figure 1). These items include “adherence to continuous quality improvement (CQI)” and a citizen’s “right to health”, through to more Māori-directed factors like “Indigenous rights” and “Te Tiriti o Waitangi”. All eight of these “concepts underpinning optimal health for Māori” are discussed in detail in the Plan.

The conceptual framework retains what Ramsden has framed as “health practitioner as a navigator and border worker to the health care ecosystem.” This recognises the ongoing importance of the mediation that medical practitioners do across the differing social, cultural and indeed emotional borders between patients and the interconnected stakeholders, organisations and structures in the healthcare ecosystem that contribute to the health of individuals and communities.

Four broad cultural safety “proficiencies”, consistent with Ramsden’s original thesis, exemplifying a culturally safe medical practitioner were identified and described (Figure 3).

These are the abilities to a) engage in ongoing development of critical consciousness, b) examine and redress power relationships, c) commit to transformative action, and d) ensure that cultural safety is determined by patients and communities served. Each of these proficiencies is then described in depth with reference to relevant literature (Figure 4).

Within each cultural safety proficiency there are five “enabling proficiencies” (Table 1) that the practitioner should be equipped with following cultural safety education and training.

For each proficiency, there are suggested teaching methods and activities and assessment tasks or CPD activities (Table 2).

The training plan goes on to provide guidance to colleges for the plan’s implementation. This begins with stressing the need for colleges themselves to create a strong culturally safe organisational environment as a firm foundation. It then describes the need to implement the training into curricula, taking into consideration particular needs and resources of the specialist colleges, and stresses the importance of employing appropriate educators, trainers and supervisors without putting undue cultural load on Māori practitioners.

Discussion

The journey of cultural safety training for medical practitioners in Aotearoa New Zealand, particularly in relation to Māori health, is marked by significant milestones and collaborative efforts among key stakeholders, including the MCNZ, Te ORA and the CMC. The integration of cultural competence and then cultural safety into the standards of the MCNZ and its introduction into medical vocational training programmes by the CMC reflects a broad commitment to embed cultural safety as a core practitioner competency, the promotion of culturally safe practices in healthcare environments and the addressing of Māori health inequities.

Regarding cultural safety, the importance of self-reflective practice, power relationships and patient determination of culturally safe care has always been to the fore. The shift by the medical profession from cultural competence standards to the inclusion of cultural safety signifies the recognition of the limitations of skills-based approaches and the need for deeper reflection on power, privilege, racism and bias within healthcare settings.¹³ It is worth noting that, reflecting its origins in Ramsden’s work, the term “cultural safety” is primarily used in Aotearoa New Zealand. Other jurisdictions focus on cultural sensitivity, cultural competence, cultural appropriateness and cultural awareness and, where they do use the words “cultural safety”, they often have yet to broach the issues of self-reflective and transformative practice.

The Cultural Safety Training Plan for Vocational Medicine in Aotearoa provides a structured framework for developing cultural safety skills among medical practitioners. It will require strong leadership from colleges to implement and then to have their graduate fellows effectively navigating the complexities of healthcare ecosystems and the pursuit of health equity outcomes for Māori and other culturally diverse populations. And this will require robust evaluation—not least because the medical workforce and its associated infrastructure are being sorely tested by under-resourcing at the present time.

There are significant challenges ahead for the integration of this programme into medical colleges producing systematic change. Although cultural safety is taught in medical schools, a large proportion of the medical workforce is internationally trained, and medical colleges can only effect change through CPD rather than years-long vocational training. Secondly, there is a limited evidence base for cultural safety standards and training programmes improving health outcomes for population groups, like Māori, who have pervasive health inequities.¹⁴ More research is needed to evaluate the training plan and build the evidence base for cultural safety interventions. Finally, cultural safety programmes have a far wider application than Māori health. Indeed, a recent Te ORA cultural safety symposium in March 2024 involving six different Indigenous jurisdictions and various Aotearoa New Zealand health institutions and medical colleges noted that health inequities are endured by other cultural groups, including those with diverse gender identities and sexualities, and the disabled and immigrant communities. While there is a need for a stand-alone Hauora Māori teaching programme that incorporates cultural competence, cultural safety and the creation of culturally safe environments for Māori doctors, there is also a need for teaching framed specifically around other groups with diverse cultural needs.

Perhaps we simply need to train more doctors from these populations of need. This too would serve Ramsden’s original thesis on cultural safety, which, while rooted in her concern for Māori health, was an attempt to address the safety of all marginalised groups. It is also interesting to note that the development of cultural safety in the medical field has been incremental and slow-moving, reflecting perhaps a very conservative stance on change. It started with the acquisition of a knowledge base, moved then to the development of skill-based competencies and, only recently, to the acquisition of a reflective cultural safety practice. Ramsden, on the other hand, was able move directly, despite some significant resistance, to cultural safety. Māori health professionals have maintained her imperative in medical schools, teaching all three in one integrated Māori health-focussed programme.

In addition, in our previous enquiries with Māori doctors themselves,^8,9,10 doctors consistently mentioned “cultural load”—those additional workplace tasks outside of the standard job description that are placed on the shoulders of Māori doctors because they are Māori. This research provides considerable evidence that this is a very real workload with its attendant stresses and pressures and that the working environment for Māori doctors is often unsafe. This warrants further research.

To implement the cultural safety training plan effectively, it is also crucial that clinical educators themselves practice cultural safety. The proficiencies of the training plan should be applied beyond patient care and integrated into teaching, clinical supervision, assessment and creating culturally safe learning environments.^15,16 This will include developing strategies for continuous learning and reflection on cultural safety in a clinical educator’s teaching practice.

In conclusion, the emphasis on cultural safety training in medical education represents a positive step towards promoting health equity for Māori and addressing systemic barriers in healthcare delivery. By embracing the principles of cultural safety, medical practitioners will aspire to create inclusive and culturally safe environments that prioritise the wellbeing and autonomy of all patients, irrespective of their cultural backgrounds.