A qualitative exploration of cultural safety in nursing from the perspectives of Advanced Practice Nurses: meaning, barriers, and prospects

The right to health was recognised as a human right in the 1966 International Covenant on Economic, Social, and Cultural Rights. According to the United Nations Office of the High Commissioner for Human Rights (OHCHR), healthcare services must be culturally appropriate and acceptable [1]. The International Council of Nurses (ICN) Code of Ethics states: “Inherent in nursing is a respect for human rights, including cultural rights.” [2]. As nursing care is delivered within a social context, it is affected by healthcare contexts and policies. The importance of culturally appropriate and acceptable healthcare is steadily increasing with the increasing pluralism, diversity, and complexity of ethnic and cultural groups [3].

Health equity aims to eliminate disparities and achieve optimal health. Existing guidelines mention the discrimination of people who do not have territorial or social access to health care services. In this context, the culturally acceptable meaning of access is still debated [4]. Access to healthcare services is affected by geography, ethnicity, sex, and socioeconomic status. Globally, in-country mobility and rural–urban migration patterns add to growing diversity. Hence, accessible healthcare is an issue that is not only available in indigenous populations but also among people with different migration patterns and their descendants. Subpopulations have specific risks and exposures that must be addressed in healthcare. In the United States, the National Institutes of Health (NIH) introduced standards to enhance culturally and linguistically appropriate services (CLAS) to be adapted to any healthcare setting to improve equity and eliminate healthcare disparities [5]. The new European Agenda for Culture of the European Council calls on research on cultural crossovers, assessing the impacts of culture in different fields, including health and well-being [6].

Even in countries where cultural safety accreditation standards and policies exist, they may not necessarily be implemented [7]. Perry et al. (2015) have demonstrated that during the clinical assessment of patients from culturally and linguistically diverse backgrounds, nurses frequently rely on patients’ poor language skills, use family members or patients’ friends as interpreters, and/or do not discuss the cultural aspects of health for fear of offending patients [8]. Healthcare providers establish interventions for their individual and professional definitions of ‘appropriate’ care. There is an ingrained assumption that healthcare professionals are solely responsible for this because of their expertise. Discussions on patient autonomy, partnership, and informed consent are ongoing. However, the premise of equal treatment for all patients is insufficient, as it simply ignores existing differences [9]. To ensure high-quality care, detailed biography and needs/resource assessments are required. Patients need space for self-definition, including their respective life experiences and experiences of the care process [10]. Accordingly, governments have committed to improving access to healthcare, enriching health service delivery, improving the quality of service and patient safety, and increasing the efficiency and coordination of care [11].

Safe healthcare services should be adequate in several dimensions such as culture. Culture is a highly context-dependent concept explained as “a patterned behavioural response that develops over time as a result of imprinting the mind through social and religious structures and intellectual and artistic manifestations.” [12]. Unless this definition of culture is acknowledged in healthcare, socio-cultural practices that are ethically, socio-politically, economically questionable, and even oppressive are perpetuated [13, 14]. It consists of all strong indicators for seeking novel approaches to heed culturally safe patient care. Curtis et al. (2019) thoroughly discussed why cultural safety rather than cultural competency is required to achieve health equity. Based on their findings, they proposed the following definition of ‘cultural safety’:

Cultural safety deals with the balance of power between professional caregivers and people receiving care. Accordingly, professional caregivers must recognise that a person’s dignity and right to self-determination have to be acknowledged and prioritised; address their own biases, attitudes, assumptions, stereotypes, prejudices, structures, and characteristics that may affect the quality of care; and engage in self-reflection. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity. Cultural safety requires healthcare professionals and their associated organisations to influence healthcare to reduce bias and achieve equity within the workforce and working environment [15].

Wilson et al. (2022) critically analysed cultural safety education and its translation into practice, focusing on indigenous health education programs. They demonstrated that even in countries where cultural safety is a well-established concept, the change in practice is complex, requiring leadership for a multi-system approach, critical pedagogy, and commitment by nurses. Educational programs for building consciousness are required to have an impact. Education is a change agent; however, it is only one part of the complex and interdependent change process to achieve culturally safe patient care. Understanding how nurses practice cultural safety in local contexts is essential to forge changes at the individual, educational, and organizational levels [16].

Comprehensively assessing cultural safety may improve our understanding of these phenomena, identify areas for improvement, and promote cultural re-engineering strategies that improve patient safety [17, 18]. In this study, we explored the culturally safe practices of ADVANCED PRACTICE NURSES (APN) in the German language context. According to the ICN, an advanced practice nurse is “a registered nurse who has acquired the expert knowledge base, complex decision-making skills, and clinical competencies for expanded practice, the characteristics of which are shaped by the context or country in which [she or he] is credentialed to practice.” [19]. Their focus is on direct clinical practice, addressing the health needs of populations, individuals, and families with additional expertise in health promotion and disease prevention [20]. In German-speaking countries, the integrative model of APN proposed by Hamric and Hanson [21] is widely used to describe APN core competencies, namely guidance and coaching, counselling, evidence-based practice, leadership, and collaboration [22]. It is important to understand that the educational model is an agreement between tertiary institutions to promote and professionalise nursing practice. The role of the APN is not recognised by any regulatory or government body in the respective countries [23‐27]. In Austria, Germany and Switzerland, nurses can obtain a Master’s degree, but there are no career paths or clearly defined roles for APNs. Unlike APNs, the Registered Nurse designation (RN) is a governmental attempt to register practicing nurses, and since there is no re presentative body for nurses, there are no requirements other than to join the register. Compared to RNs or Advanced Practice Registered Nursing (APRN) roles, APNs are academically educated nurses, thus by fulfilling an expanded nursing role and performing broad competencies in healthcare, they may be able to create awareness and serve as role models for cultural safety. Therefore, this study aims to explore the concept of cultural safety from an APNs’ point of view by identifying existing barriers, opportunities, and practices.

This qualitative exploration consisted of two phases: semi-structured interviews to develop new knowledge of the research phenomenon and a nominal group meeting to discuss the findings, collect more detailed data, and validate the information power of the data collected in Phase 1.

In 2016, Bozorgzad et al. wrote: “Healing occurs in a safe milieu, and patients feel safe when service providers view them as whole persons, recognizing the multiple underlying factors that cause illness. Cultural safety can lead to service delivery in this way, but most nurses have no clear understanding of this concept.” [37]. The findings of this study confirm that the APNs do not have a clear understanding of the phenomenon of cultural safety. The admitted APNs were equally ambivalent and lacked knowledge of established concepts, such as transcultural nursing, equity, cultural awareness, cultural safety, or respective competencies. They expected the nursing curriculum and continuous education to increase their cultural competencies, but they did not understand that the concept of cultural safety goes far beyond the acquisition of information, such as religious or dietary needs. Some of the APNs eagerly proposed their definitions of cultural safety, arguing that cultural safety acknowledges the importance of patient-family centred approaches and may help avoid stereotyping patients and their families based on their language, culture, religion, or ethnicity. Similarly, the international literature suggests that approaching the patient, emphasizing on the humanistic aspects of care in terms of hope and life, reducing the feeling of loneliness during hospitalization, paying attention to patients’ needs, sympathizing, and respecting them, and taking their concerns seriously can promote the feeling of safety among hospitalized patients [38].

Heeding cultural safety concerns healthcare staff as much as it concerns patients. Patient safety programs often underestimate the relationship between culture, language, and safety and quality of care [39]. This calls for organizational change that ensures appropriate communication with patients and their families, and supports policies that put in place improvement strategies [40‐42], such as reflection rounds or cultural safety briefings at their workplaces [43‐45]. Ideally, the education and deployment of nursing experts with a focus on cultural issues would be helpful [46]. Discrimination and even indifference towards patients who do not speak the language may have damaging consequences for patients, affecting their emotional, spiritual and physical wellbeing [47]. Our study findings indicate that patients who were unable to communicate due to poor language skills were systematically left without care. This is a clear example of a lack of access to healthcare and a lack of health equity in healthcare facilities. Taking care of people who do not understand the language or who are poorly educated takes more time and can be emotionally draining. Compensation and support should be offered to nurses taking over a mediating role. Culturally diverse nurses are considered assets in terms of language skills and cultural competencies when cultural clashes emerge. However, in our study, culturally diverse APNs admitted their familiarity with prejudices, discrimination, and racism, which was presented as a taboo topic. Whereas, patient safety culture and the second victim phenomenon has been described as causing distress in nurses [48], this study emphasises the first victim experience in culturally diverse nurses.

Power represents an essential distinction between cultural competence and cultural safety [15, 16, 37]. Healthcare providers should reflect on interpersonal power differences and acknowledge the power differences between nurses and patients. The topic of power was not discussed in our explorative study, which could be because of the traditional development of nursing in German-speaking countries. Nursing as an independent and academic discipline has developed very slowly in Austria, Germany, and Switzerland, compared to the international context. In Austria, basic training in nursing was shifted to the tertiary level with a change in the law in 2016 [49], university and academic training in nursing is still a much-discussed topic. The service to the patient according to the principle of Christian charity is in the foreground, strictly maintaining the attitude that the doctors order the interventions and the nurses perform them. In many cases, there is still a lack of awareness of one’s own professional role and the power it entails in the relationship between patient and nurse.

The issue of visiting relatives divided the APNs. Large families were perceived as a source of support and taking on caring responsibilities, but others saw it as a hindrance due to noise and disturbance. Despite ongoing criticism of the exhaustion of family members as interpreters [50], relatives were perceived as helpful in overcoming communication barriers. Supporting relational, culturally safe care focuses on building the conversation, engaging the family, closing the conversation gap and improving health literacy to reduce power imbalances [15]. Some nurses found it personally and professionally fulfilling to be proactive in informing, involving and communicating with family members to better understand the patient’s needs.

Nurses need to evaluate and question their cultural backgrounds and adapt their behaviours rather than pushing for the mere acquisition of competencies in different cultures and religions [16]. APNs admitted that they do not provide culturally safe care, but unanimously asserted that they strive to provide such care. They cited several characteristics of safe patient care in terms of removing language barriers and overcoming misunderstandings as the first step in building a professional nursing relationship. It became clear that reflecting on one’s own values, attitudes, assumptions, prejudices and stereotypes is essential for culturally safe care. Nurses mentioned that self-reflection must be an ongoing process to ensure culturally safe care on a continuous basis. Our study described many components that can contribute to improving cultural safety. Previously introduced concepts such as transcultural care, cultural sensitivity, cultural awareness and competencies were interpreted as prerequisites for cultural safety. Other important aspects were professional flexibility, openness and tolerance of nurses in caring for culturally diverse patients and their families. In addition, APNs argued that an atmosphere free of intimidation and fear promotes overall health [38, 48]. Accordingly, the concept of cultural safety offers the possibility of ensuring better access to healthcare for culturally diverse patients and their families in pluralistic societies [51].

Communication difficulties, insufficient language skills, different perceptions and expectations of care and treatment outcomes were mentioned as important aspects of cultural safety in German-speaking health facilities. There is a need for self-reflection sessions and translation services for nurses responsible for the care of patients with diverse cultural backgrounds in order to improve equality and the feeling of safety during the hospital stay. In addition, the presence of prejudice, discrimination and even racism in the healthcare culture should be assessed and remedial strategies developed and implemented using diversity management and leadership. Education and training are needed to bridge the gap between the perceived educational needs of nurses and the requirements of safe care, and to address challenging personal behaviours in the multicultural healthcare environment. Future studies should examine the impact of cultural safety improvement programmes on patient care outcomes.