Implementing a cultural safety training plan across medical colleges in Aotearoa New Zealand—looking back, and looking forward

Providing culturally safe care to patients, whānau (family groupings) and communities is an important contributor to equity and to creating conditions for optimal health, particularly for Indigenous populations and other groups that experience marginalisation. Achieving this requires understanding that cultural safety addresses the structural and interpersonal factors within healthcare that contribute to disparities, recognising that the quality and safety of care is determined not by health practitioners’ intentions but by the experiences and outcomes of those receiving care. Without culturally safe practice, healthcare systems risk perpetuating the very inequities they aim to address.

Medical training in Aotearoa New Zealand has seen renewed focus on cultural safety since 2019, propelled by a systematic literature review,¹ a well-attended symposium² and Te Kaunihera Rata o Aotearoa | Medical Council of New Zealand’s (MCNZ) updated definition of cultural safety in that same year.³ Work to determine the current state of cultural safety^4–6 contributed to developing the Cultural Safety Training Plan for Vocational Medicine in Aotearoa 2023 (the Training Plan).^7,8

The Training Plan was a joint undertaking between Te Ohu Rata o Aotearoa (Te ORA) | Māori Medical Practitioners Association and the Council of Medical Colleges (CMC), the collective voice for 18 medical colleges in Aotearoa. The Training Plan emphasises that while it is important to retain a focus on both hauora Māori (Māori health) and cultural competency, there is a need to clarify the distinction with cultural safety and ensure it is included in teaching, continuing professional development (CPD), curriculum development and in the activities, policies and practices of each medical college.

Following the release of the Training Plan in February 2023, CMC underwent a programme of work to support medical colleges to implement and integrate the Training Plan, with a view to fully evaluating this programme after 4 years (early 2027). This article provides a mid-point review of the first 2 years of implementation, and guidance on shaping support and activities going forward.

Overview of the Training Plan

The Training Plan articulates four key proficiencies that embody the definition of cultural safety. It requires that culturally safe medical practitioners:

1. engage in the ongoing development of critical consciousness;
2. examine and redress power relationships;
3. commit to transformative action; and
4. ensure that “cultural safety” is determined by patients and communities served.

For each key proficiency there are five enabling proficiencies that provide more detailed direction and guidance along with suggested teaching methods, activities, assessment tasks and CPD activities (see page 20–21 of the Training Plan for a summary rubric of these proficiencies, plus teaching and assessment activities⁷). A conceptual framework identifies the health practitioner as a navigator and “border worker”, situated in the space between patients, whānau and communities and the wider healthcare ecosystem. Key elements underpinning the Training Plan include: Te Tiriti o Waitangi; social justice; equity; health equity for Māori; actively challenging racism; continuous quality improvement; the right to health; and Indigenous rights. The central goal is to actively contribute to optimal health for Māori and all groups in the population that experience inequities in healthcare. The Training Plan was designed so that it could be implemented across the different vocations in the various colleges, with the flexibility to allow colleges to integrate aspects specific to their field.

Implementation of the Training Plan

To support implementation, a cultural safety contractor position (0.15 full-time equivalent) was established and worked with CMC leadership to facilitate the following activities:

• the launch of the Training Plan followed by a full-day cultural safety workshop;
• the establishment of a cultural safety rōpū (group) that met regularly online;
• the development of an online cultural safety resource “kete” (collection of cultural safety resources);
• the organisation and facilitation of a Cultural Safety Day in July 2024;
• the establishment of a communication platform to allow connection between colleges; and
• the provision of individual guidance and support to colleges when needed.

This review provides the opportunity to reflect on the past 2 years’ learnings, and draws on the insights and experiences of those closely involved. It identifies what worked well and what were the challenges and potential solutions, and it articulates several recommendations to guide activities going forward.

Looking back—medical colleges’ experience of the Training Plan and implementation

Overall, users of the Training Plan rated the effectiveness, relevance and usefulness of the proficiencies and the training and assessment activities as excellent. It was viewed as a useful and quality resource, with flexibility to meet college needs. The descriptions of key concepts helped provide clarity, particularly the distinction between cultural safety and cultural competence, and clear direction on what could be done to move toward the goal of a culturally safe workforce.

In the 2 years since its inception, the Training Plan has been used in a variety of ways: in curriculum development and review; in CPD; to shape graduate profiles; as a framework for peer group training; as a basis for resource development; and has been adapted to use as a college audit tool. It has been described as instrumental in bringing cultural safety to the forefront and creating momentum, leading the colleges into a new space.

Some feedback noted that the high level of detail in the plan meant it was a lot to work through, adding to an already significant workload for those in curriculum review. It was also felt that the material would be enhanced with the inclusion of whānau and community perspectives through vignettes or scenarios, and resources to facilitate implementation and assessment. Tailoring the proficiencies to each specific vocation, demonstrating and authentically assessing the activities remains a challenge.

The February 2023 launch and workshop was well received by approximately 140 participants, helping embed key concepts and promote collaboration. Similarly, participants valued the Cultural Safety Day held in June 2024. The day’s schedule included presentations from: a local Māori health provider; medical students with their research on student experiences; MCNZ with updates of their recent activities; and one of the authors of a cultural loading project, which has since been published.⁹ The day also provided the opportunity for colleges to share their learnings, and included an interactive group activity to discuss current challenges and potential solutions. Participants valued the opportunity to connect and collaborate in person (following many online meetings); they enjoyed the workshops and discussions and found the presentations informative, particularly commenting on the diversity in the range of speakers and speaker topics.

Throughout the year, individual support for colleges was made available when requested, which was found to be valuable, particularly in troubleshooting specific challenges. Some college representatives felt they could have made better use of this facility.

The cultural safety rōpū consisted of those in each college involved in education, CPD and curriculum development, and it numbered approximately 40 members. This group met online for 90 minutes every 6 weeks in order to: socialise the Training Plan; provide opportunity for deeper exploration of cultural safety issues; share resources, activities and strategies across the colleges; and for guest speaker presentations from experts in the fields of cultural safety, medical education, equity and anti-racism. Participants found these meetings informative and useful, and the recordings and transcripts were a valuable resource, particularly for those unable to attend. The rōpū helped build critical mass, supporting those championing cultural safety and equity, and was useful for reflecting on each college’s journey. At times, resource sharing across the colleges could lead to a sense of vulnerability and some intellectual property concerns. However, the process of regular meetings in a non-competitive space helped build connection and trust across colleges and a safe environment to share learnings.

Some improvements for the rōpū were identified, such as more clearly defining the audience for each meeting so that content could be tailored accordingly—for example, sessions specifically for management, or for educators. Cultural safety rōpū participants valued demonstrations on how the Training Plan could be used, particularly the sessions that were structured as a mini lesson derived from the Training Plan. This would be further enhanced by practical, authentic examples of cultural safety in practice, particularly from patient and community perspectives. A strengthened focus on patients and whānau is needed, as is a focus on the taiao (the natural environment) to connect this work with climate change commitments.

Incorporating cultural safety into curricula requires time and consultation; some colleges initially attempted to embed these responsibilities into existing workloads only to find that more dedicated resources were required. Ensuring specific cultural safety roles, securing funding and having strong champions were seen as critical to success. The limited influence in the private sector was noted as a challenge. As profit-driven commercial businesses, these workplaces need to see cultural safety as important, and be self-motivated to implement strategies.

Ensuring the responsibility for cultural safety is distributed within the college helps reduce the cultural loading of Indigenous staff and fellows. Workforce and capacity remain a challenge. There is a need for proficient cultural safety educators to teach those who are training others, and to deliver training to college supervisors, staff and fellows. Specific training is needed for onboarding new staff and for international medical graduates.

The eighteen medical colleges vary in size, capacity, infrastructure and resources, and ideally require different approaches for their different needs. Several colleges operate across the two jurisdictions of Aotearoa and Australia. Current and historical definitions and understandings of cultural safety and associated key concepts vary between (and within) the two countries. The Training Plan provided clear descriptions of the three central key concepts (cultural safety, cultural competency, hauora Māori), and regular socialising of these definitions saw a shift toward consistency of language; however, variations in use of terms persisted among the rōpū and within the colleges. Clarification is required, as well as consistent reiteration of the concept descriptions in order to work toward a shared language. This situation reflects current research on refining these definitions,¹⁰ and the differences in definitions between the MCNZ and the Australian Medical Council (AMC).¹¹

While self-reflection and reflexivity is an integral part of critical consciousness development, cultural safety needs to move beyond this to practical application and habitualisation of culturally safe practices. There was some concern that self-reflection, and even peer-group and supervisor feedback, might create an “echo chamber”, reflecting back existing cultural mores, creating a false sense of safety and comfort and not leading to transformative change. There is a need for authentic patient, whānau and community feedback, and objective external reference points.

Critical consciousness development, a core concept in cultural safety, is an ongoing and even lifetime journey. There is often the perception that obligations have been met at the completion of training modules. To counter this, cultural safety training needs to be regular and processes should be put in place for practitioner demonstration of ongoing feedback loops from patients, peers, supervisors and communities, and of their associated transformative and sustained change in practice. Embedding these as standards can also be useful for shifting habits in those who are “not on board”. Encouraging individuals and institutions that are resistant to change remains an ongoing effort, particularly in an adverse political environment. Governance structures in colleges are sites of decision making, and scrutiny for equitable representation is required, particularly noting the importance of having Indigenous representation and voice. Cultural safety and clinical safety are mutually dependent and institutional commitment should reflect this.

Looking forward—where to from here?

There is an identified need for a range of resources, particularly those that help move from theory to practice. A “cultural safety toolkit” was under development at the time of this review and has since been released (this can be found at the CMC website: www.cmc.org.nz). Real-world examples showcasing cultural safety in practice in a variety of contexts, both from the perspectives of patients/whānau and health professionals, would be valuable as teaching and learning resources, and provide authentic examples of cultural safety in action.

Other potential learning materials could include vocation-specific resources, online training options, scripted training videos, assessment activities and a scripted podcast series with guest speakers leading in this area both locally and internationally. Broader information technology could integrate resources as much as possible, so that training can connect directly to individuals’ CPD plans.

There is support for continuing the annual Cultural Safety Day (the second Cultural Safety Day was held on 30 July 2025 following this review) and suggestion of a biennial mini conference with international presenters and streamlined sessions to accommodate varying experience levels. As cultural safety is an area currently undergoing significant development, updating the Literature and Environmental Scan of Cultural Safety in Medical Training⁶ could be useful, as well as an update of the 2021 Cultural safety within vocational medical training⁵ to review college activities and understandings, 5 years on.

The Training Plan was largely designed for application at an individual practitioner level. While this is important, it is limited in affecting overall sustained institutional transformation. A focus on college-level institutional change and paradigm shift is required, and the idea of a cultural safety audit tool has been considered. The AMC and MCNZ are currently undergoing a review of cultural safety standards, which is due for release this year. When finalised, colleges will be required to provide evidence against these standards as part of their assessment and accreditation, thus serving the function of an external audit.

Broadening cultural safety’s scope to include horizontal (workforce) and institutional dimensions would be valuable. This wider scope should include detail for all three concepts: critical consciousness development, cultural competency and Indigenous health, with enabling proficiencies for each. Cultural competency is currently described in the Training Plan as the knowledge and skills required to work cross-culturally. This could be broadened and more clearly defined to include: effective communication skills and relationship development; community knowledge, engagement and connection; understanding different ethnic and other cultural groups in the community; and demographic and epidemiological information on the specific community served, including quality ethnicity data. This may also be where a focus on the connection to the wider natural environment will most readily sit.

The Training Plan was developed in Aotearoa, specific to this context. However, given that there are many trans-Tasman medical colleges, the Training Plan was often described as an enabler for prioritising Indigenous health in the Australian context. Some reorientation of the Training Plan is required so that it is more readily applicable in both Aotearoa and Australia, and inclusive of the variations in cultural safety interpretation.

There is support for the cultural safety rōpū transitioning to a mix of webinar-style sessions and facilitated interactive discussions, with sessions tailored to specific audiences. Alongside this, a suitable communication platform with ready access for college members would be useful for the cultural safety rōpū members to maintain connection. A regular email newsletter was suggested and training was requested for those who are teaching cultural safety within the colleges.

Finally, over the course of CMC activities, a desire for further development was expressed, in particular, on cultivating critical consciousness. This is an area of constant transformation itself, and includes a broad range of topics such as anti-racism, identifying bias, critical race theories, examining hierarchies, communication skills and power dynamics. Participants appreciated the exploration and activities that had been undertaken over these 2 years, and felt it would be beneficial to go deeper into the range of topics possible.

Conclusion

Ensuring culturally safe practice and environments is an ongoing journey for practitioners and medical colleges. Many gains have been made in the first 2 years of implementing the Cultural Safety Training Plan for Vocational Medicine in Aotearoa. This mid-point review provides practical guidance for CMC and colleges to continue promoting culturally safe practice and creating culturally safe institutions, contributing to equity and the realisation of health potential for Indigenous populations and all communities served.