Module 4: Trusting, Compassionate, Therapeutic Relationships – Topic B Demonstrate how to provide welcoming and culturally safe spaces when providing care or services to persons who use opioids.

Learning Objectives

By the end of this topic, the student should be able to:

• Describe and define the concept of cultural safety and terms related to cultural safety.
• Explain how a welcoming and culturally safe space fosters a trusting, compassionate, and therapeutic relationship when working with people using substances and their families.
• Explain how trust and compassion are fostered by practices that support cultural safety.

Key Concepts

• Cultural safety is an approach created to disrupt stigmatizing practices that reproduce oppressive health delivery.
• Cultural safety lies upon a continuum of care that involves the related concepts of cultural awareness, sensitivity, and competence.
• Practising from a culturally safe place has shown to result in more positive and equitable experiences for those seeking help.

What Is Cultural Safety?

The term “cultural safety” is often used interchangeably with related concepts, including:

• cultural awareness,
• cultural sensitivity, and
• cultural competence.

There are subtle definitional differences in the concepts above that we will elaborate on below. These concepts are not interchangeable; they are best viewed as parts of a continuum of care, with cultural safety as the desired outcome (Wabano Centre for Aboriginal Health, 2014).

Continuum of Care

(Wabano Centre for Aboriginal Health, 2014)

• The continuum starts with cultural awareness, which is essentially the acknowledgment of difference.
• The next phase of the continuum focuses on respecting that difference, which we call cultural sensitivity.
• From there, the focus is on the service provider’s skills and attitudes, and this is cultural competence.
• Cultural safety includes the skills of the previous phases but adds a self-reflection component for the service provider; it “analyzes power imbalances, institutional discrimination, colonization, and colonial relationships as they apply to health care” so that power is negotiated and service becomes client-driven, with the receiver of care determining the desirable outcomes (National Aboriginal Health Organization, 2009, p. 1).

The idea is that self-reflection for the health and social service professional leads to empathy and advocacy, which result in better health outcomes. The self-reflection comes from service providers acknowledging their own world view.

It forces service providers to focus on themselves and analyze how their perspective impacts delivery of care, whether positive or negative, promoting a better understanding of the person they are providing care for. Next, we will elaborate on cultural awareness, sensitivity, competence, and safety as part of the spectrum and how they can be transferred to the provision of care.

Cultural Awareness

Cultural awareness begins with understanding cultures different from one’s own, and specific to these modules, the culture of substance use. This may mean spending time learning about cultures different from one’s own or cultures that are cared for within the context of substance use/misuse.

Because cultural identity can be complex, introductory questions might include:

• “Is there anything that you would like me to know?
• What do you need?
• Would you prefer to have someone else involved?
• Is there something that I can do to help you feel more comfortable here?

Framing introductory questions this way allows individuals to ask for practices other than the dominant world view offered to them.

Cultural Sensitivity

Cultural sensitivity in health care is defined as a provider being “sensitive to the ways in which community members’ values and perceptions about healthcare are different from his or her own” (Goicoechea-Balbona, 1997).

Attitudinal change by the health and social service provider is critical in creating cultural sensitivity, where difference is honoured and celebrated. Inclusion is reflected in health and social spaces that acknowledge and celebrate cultures that are different than the provider’s own: a place where everyone feels accepted and welcome.

This could mean:

• not dominating a public space with religious artifacts representing one world view,
• including those who speak other languages, and
• adapting to differing abilities.

Sutton (2000) suggested that cultural sensitivity be expanded into physical spaces, as it may have an impact on a clients’ response to medical services.

Waiting Rooms

• For those who are considering or entering treatment programs, which can be an anxiety-provoking experience, soothing colours and comfortable furniture with subdued lighting may be appreciated.
• Waiting rooms that are quiet may be less triggering for some people who are experiencing the physical and psychological symptoms of withdrawal (Shah & Huecker, 2019).
• Ensuring there is an accessible washroom for people in waiting areas is essential.

Accommodations

• Time – health and social service providers should recognize that some cultures may have varying conceptualizations of time. This can have an impact upon scheduling of appointments; it should be the starting point of discussions about late or missed appointments to avoid presuming a dominant world view related to time.
• Navigating the System – it is advised to make a system navigator available to support and advocate for the individual if language, mental, or health literacy is an issue.
• Space – in hospital settings, chapels are commonly used as a space where clients can seek quiet reflection. However, it should not be presumed that this is appropriate or sufficient for people of all cultures. Culturally sensitive practice means asking questions about people’s specific needs.
• Cultural practices – a known cultural practice for some Indigenous people is smudging – typically involving prayer and burning of sacred medicines (sage, cedar, sweetgrass) (Robinson, 2018). Culturally sensitive care involves accommodating this practice, which might include practical tasks such as temporarily pausing automatic smoke detection.

Cultural Competence

Cultural competence is generally defined as “the ability to understand, appreciate, and interact with people from cultures or belief systems different from one’s own” (DeAngelis, 2015, p. 64).

Culturally competent health and social service providers possess the knowledge and skills needed to respond to sociocultural issues that are part of clinical encounters. Cultural competence requires an attitude of openness and a willingness to:

• listen
• learn
• collaborate, and
• negotiate (Fahlberg, Foronda, & Baptiste, 2016).

When this degree of attitudinal change occurs, it is sometimes referred to in the literature as cultural humility.

Cultural competence training can include:

• understanding the central role of culture in all lives and how it shapes behaviour;
• respecting and accepting cultural differences;
• learning to effectively use culturally adapted and culturally specific practices; and
• continually developing awareness of one’s own personal cultural influences and prejudices or biases (Hark et al., 2009; Purnell, 2012).

Health and social service providers who strive to become culturally competent or practice cultural humility with those they work with have been shown to have a significant and positive impact on those clients.

• Provider’s increased cultural competence has been linked to increased client satisfaction (Castro & Ruiz, 2009; Paez et al., 2009), treatment adherence or compliance (Smedley et al., 2003), and the seeking and sharing of information with the provider (Safran et al., 1998).
• Sutton (2000) provided a self-check assessment for physician providers on cultural competence that addresses the physical environment, communication, and values and attitudes (Figure 2).
• The purpose of the self-assessment is to identify areas that, if improved upon, can in turn improve the quality of services provided to culturally diverse groups of people.
• Although written for the physician provider, the domains that Sutton (2000) addressed are applicable to any health and social service provider working in the field of substance abuse disorders.

Cultural Safety

Health and social service providers should routinely check their own assumptions. They must ensure interactions are characterized by empathy and compassion that are reflected in the tone of their speech, and the degree to which clients are engaged in decisions that impact their recovery.

The Role of Power

The distinguishing feature that makes the stage of cultural safety different from the earlier three stages (cultural awareness, sensitivity, and competence) is the recognition of power that the health and social service provider holds (Laverty et al., 2017).

• This stage requires health professionals to reflect on interpersonal power differences (their own and that of the person they are working with) and how this power plays out within the different contexts of care (admission, treatment goals, care plans, and discharge if treatment is in a hospital).
• Culturally safe health and social service providers are invited to “examine sources of repression, social domination, and structural variables such as class and power” (Doutrich et al., 2012, p. 144) in addition to “social justice, equity and respect” (McGough et al., 2017, p. 1).

The establishment of a culturally safe space fosters a trusting, compassionate, therapeutic relationship with persons using opioids or persons with opioid disorder, and their significant others.

Questions

What is cultural safety?

a. a place where people feel supported because their culture is valued

b. a physical space

c. the last stage of a process

d. all of the above

Correct! Cultural safety is both a process and a space where another’s beliefs, customs and culture, including identity, are valued, respected, and acknowledged as important. It is the last stage of a multi-phase process.

Incorrect. The correct answer is d. Cultural safety is both a process and a space where another’s beliefs, customs and culture, including identity, are valued, respected, and acknowledged as important. It is the last stage of a multi-phase process.

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Which of the following statements are true about cultural safety? (Select all that apply.)

a. It originated in India as a part of the social justice movement.

b. It can lead to better outcomes.

c. It can be achieved through self-reflection.

d. It can be achieved by asking where the person is from.

Check

Please select an answer.

Correct! Intentionally practising cultural safety produces more positive outcomes for the person who feels supported and hence motivated to change negative behaviours. Self-reflection is one way to work towards offering cultural safety.

Incorrect. The correct answers were b and c. Intentionally practising cultural safety produces more positive outcomes for the person who feels supported and hence motivated to change negative behaviours. Self-reflection is one way to work towards offering cultural safety.

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Which of the following statements reflect a culturally safe environment?

a. “I understand.”

b. “Where are you from?”

c. “Is there something I can do differently?”

d. “I know all about your history—I watched a movie last night.”

Correct! Statements that assume an all-knowing position regarding another’s culture does not offer a culturally safe space. The only statement that reflects a respect and openness is c, “Is there something I can do differently?”

Incorrect. The correct answer is c. Statements that assume an all-knowing position regarding another’s culture does not offer a culturally safe space. The only statement that reflects a respect and openness is c, “Is there something I can do differently?”

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Why is cultural safety important?

a. It is the right thing to do politically,

b. It is part of person-centred care.

c. It supports health equity and equality.

d. More people will seek treatment.

Correct! When a person’s culture and historical context are valued as part of the admission, treatment and recovery process they are more likely to be supported in an equitable and person-centred way.

Incorrect. The correct answer is c. When a person’s culture and historical context are valued as part of the admission, treatment and recovery process they are more likely to be supported in an equitable and person-centred way.

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References