1. Racism and Cultural Safety in Health Care
Dr. Richard Matthews
3 January, 2017

2. Types of unsafe practice in healthcare
Technical errors and failure
- for example, on the job mistakes, negligence and the like
- Unclean rooms, badly cooked food, slippery floors can all be unsafe.
Individual behaviors and habits can be a problem
Institutional policies can create dangers
These are all relatively easy to deal with conceptually, although actually improving them can be an immense practical challenge.
Cultural safety is quite different, although related to these.

3. Cultural safety
It is possible to be technically excellent and yet culturally unsafe.
When this happens, members of specific ethnic groups will inevitably experience worse health care, will be at higher risk of normal medical error, or will be denied access to health care altogether.
Still worse, health care practitioners may never notice these facts.
Ex. Control of health care spaces by dominant racial groups
Cultural safety is a problem, above all, of the impacts of racism upon public institutions, including health care institutions.

4. General definition of racism
The unjust organization of laws, economic practices, social habits, institutional policies and individual attitudes and behaviors to benefit a certain group while disadvantaging others.
Is about the violence generated by the ways in which some social, economic, political and legal systems are organized
This also appears in the ways in which institutions like hospitals and lodges are organized.
These systems are racist when they exploit, marginalize, disempower and cause direct violence to members of specific oppressed groups.

5. Marginalization
Marginalization refers to social processes by which groups and their members experience diminished access to health care
It is a function of systemic organization first, rather than individual choices and behaviors.
But individual actions and behaviors always play a role too.
In marginalizing people, we determine who gets access to important spaces, and who is denied them, and we do so solely on grounds of group membership, not individual character or merit.

6. Some groups are more at risk than others
Racially marginalized people
Poor people
People with disabilities
Women
Elderly people
Why?

7. A health care organization is culturally unsafe to the extent that laws, policies, structural organization of spaces, along with individual attitudes and behaviors work to marginalize specific ethnic or other distinct cultural groups.

8. Culturally safe care
Is concerned with creating respectful and inclusive spaces for otherwise racialized and marginalized groups.
Focuses on the caregiver and the caregiving institution and not on the patient
The way in which these are socially and economically positioned has implications for the care that others receive.
We have to think carefully about this, because we can inadvertently exclude people from care, or participate in the exclusionary behavior of others – just by being thoughtless. We do not need to be the (unfortunately real) violent racist that pops up in the news.

9. In working to establish a culturally safe environment, we have to think about more than behavior.
It is also about:
Attitudes
Policies
Practices and habits
Laws
The organization of spaces
All of these, singly and in combination, can create unsafe spaces for people
Ex. Racist resource allocation decisions for the nursing stations (or education, housing, sewage, property rights…..) that result in vastly inferior funding compared to similar health institutions in other parts of rural Canada.

10. Culturally unsafe care
‘unsafe practitioners diminish, demean and disempower those of other cultures, whilst safe practitioners recognize, respect and acknowledge the rights of others’ (Cooney, 1994, p. 6).
Diminish
Demean
Disempower

11. The humiliations can happen at the level of individual behavior (conscious or tacit racist, sexist or poor-bashing remarks), policies (insofar as they embed oppressive assumptions, or laws
All of these can, each in their own ways, demean, diminish or disempower members of other cultural groups.
For example, tacit stigma about indigenous people can lead to longer wait times, mistreatment and the like
Lack of respect for other epistemic traditions can mean that you don’t hire indigenous experts because of cultural preferences for mainstream medical people
Laws, and fears of law suits, can work against the inclusion of, and respect for, marginalized cultural others.

12. Any subordinated culture can be the object of unsafe care
For much of my work, the main population of concern is mistreatment of indigenous patients by hospital staff
But the care can also be unsafe if the patient is Muslim, Chinese, Jewish or any subordinated culture
It is important to recognize that culturally unsafe care can only be inflicted upon subordinated populations. This reflects the power dynamics of privilege and oppression
This is not to say that care may be unsafe in other ways for dominant group members.

13. Some take away principles of cultural safety
1. the recipient of the care judges whether it is unsafe, not the caregiver. (Gerach 2012)
So refuse the temptation to get defensive. Listen to the individual and take her seriously. Assume she is correct and find ways to have a dialogue to ensure that the unsafe care does not repeat
For example, if an individual raises a charge of racism, believe them and work to transform the behaviors, policies, practices or laws that generate the problems.
The complaint is an opportunity for dialogue
2. This requires courage, but is worth it and will result in improved care, not to mention making us better people.

14. What to do to promote cultural safety?
Listen respectfully to the experiences of racism as told by Indigenous people.
Believe them and discuss ways to improve the environment. Include members of marginalized groups in discussions about how to improve a situation, belief, practice of environment.
Share those stories with others, so that they can also understand.
Accept responsibility for our participation in racism and for the role we play in its continuation.
Pursue reconciliation by thinking about how to make the institution more welcoming and inclusive – whether it is at the level of our own behavior, attitudes and choices, intervening carefully when we witness racism of others, or at the level of organizing the space that we are working in.