CAOT Position Statement: Occupational therapy and Cultural Safety (2011)

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To engage in effective, compassionate, culturally safe practice, it is the position of the Canadian Association of Occupational Therapists (CAOT) that the profession of occupational therapy must collaborate with diverse stakeholders to ensure that understandings of meaningful occupation are being properly defined as they apply to all people within Canadian society. CAOT believes that through engagement in meaningful occupations health, well-being and justice are realized. To achieve the goal of health, well-being and justice for clients of occupational therapy, CAOT recognizes the need for building capacity for concepts of cultural safety within the profession.

Recommendations for occupational therapists:

1. Occupational therapists embrace a best practice in occupational therapy that seeks to offer effective, client-centred, evidence-based, occupation-focused enablement for health, well-being, and justice.
2. Occupational therapists utilize our foundations of enablement that honour: choice, risk and responsibility, client participation, vision of possibility, change, justice, and power sharing (Townsend & Polatajko, 2007). Occupational therapists embrace a way of thinking that enables a social theory of change through occupational enablement.
3. Occupational therapists promote cultural safety concepts in entry-level education curricula for occupational therapists.
4. Occupational therapists conduct research relating to culturally safe occupational therapy services.

CAOT Initiatives

To enable occupational therapists to provide effective, compassionate, culturally safe practices, CAOT will:

1.  Identify and develop formal alliances and partnerships with diverse stakeholder groups to create and maintain awareness and understandings of unique perspectives on issues relating to occupational therapy and clients of occupational therapy.

2.  Continue to work with members and stakeholders to develop tools that promote client –centered,
occupation based practices that can be applied across diverse cultural and social backgrounds.

3. Encourage the use of an evaluation framework to measure organizational competency and cultural safety (i.e. U.S. Department of Health and Human Services National Standards for Culturally and
Linguistically Appropriate Services). 

4. Provide continuing education and networking opportunities among occupational therapists to promote culturally safe services.

Background

1.  The term “cultural safety” was developed in the 1980s in New Zealand in response to indigenous Maori people’s discontent with nursing care. Maori nursing students and Maori national organizations supported the theory of “cultural safety,” which upheld political ideas of self-determination and de-colonization of Maori people (Adapted from National Aboriginal Health Organization [NAHO] Fact Sheet on Cultural Safety, January 2006).
  Cultural safety is an evolving term and moves beyond the concept of cultural sensitivity to analyzing power imbalances, institutional discrimination, colonization and relationships with colonizers, as they apply to healthcare. It is important to understand that there are power differences inherent in interactions between health professionals and clients, and that professionals need to approach care from a perspective that the professional may be situated in a cultural group that is “other” from the client. Professionals need to uncover any any assumptions and limited knowledge about the other person (Polachek, 1998). Cultural safety is near the end point of the continuum of cultural awareness, culturalcompetence and cultural safety. Culturally safe care involves lifelong learning and continuing competence (NAHO, 2008).
  Cultural safety requires that healthcare professionals become respectful of nationality, culture, age, sex, gender and sexual orientation , political and religious beliefs. This notion is in contrast to transcultural/multi-cultural care, which encourages healthcare providers to deliver service irrespective of these aspects of a patient.
  A key element of culturally safe practice is establishing trust with the patient. Culturally safe care empowers people because it reinforces the idea that each person’s knowledge and reality is valid and valuable. It facilitates open communication and allows the client to voice concerns about care that he or she may deem as disrespectful or unsafe. Disrespectful care may be deemed ineffective and unsafe such as when the client is humiliated, alienated, or directly or indirectly discouraged from accessing necessary care.
  Cultural safety involves recognizing the healthcare professional as the bearer of his or her own culture and attitudes, and that healthcare professionals consciously or unconsciously exercise power over patients. Cultural safety is a socio-political idea because it attempts to educate and change health professionals’ attitudes about their power relationships with their patients. Cultural safety involves acknowledging the history, contributions and wisdom of social groups, as in the example of Aboriginal traditional knowledge and medicine practices.
  Adopting a culturally safe approach to health care can benefit individuals, providers and health care systems. With culturally appropriate care clients respond better and health care providers have increased confidence to address diverse needs of social groups (NAHO, 2008)

2. Occupational therapists are committed to promoting an equitable Canadian society through to practicing in ways that are accessible, welcoming, meaningful and effective for people from diverse social and cultural backgrounds (CAOT, 2007). These views are captured and promoted in the guiding occupational therapy document, entitled, Enabling Occupation II: Advancing and occupational therapy vision for health, well-being, & justice through occupation (Enabling Occupation II) (Townsend & Polatajko, 2007).

3. The Enabling Occupation II document presents:
• A vision for occupational therapy entrenched in occupational enablement and promotes a worldview in which participation, collaboration and power-sharing are core constructs. The vision challenges us to transform our client-centred practice to one of health, well being and justice through occupation for our clients.
• Enablement foundations that shape enablement reasoning and are conducive with a culturally safe approach. These foundations consist of the following key concepts: choice, risk and responsibility, client participation, vision of possibility, change, justice, and power sharing (Townsend and Polatajko, 2007).
• The Canadian Model of Client Centred Enablement and the enablement continuum engage therapists to critically reflect and make changes to practice to avoid situations of missed enablement, minimal enablement and ineffective enablement.
• The Canadian Practice Process Framework acknowledges the contextual elements of practice and encourages therapist to reflect on the impact contextual factors may have at all points of action within the therapists- client collaborative process.

4 . The U.S. Department of Health and Human Services National Standards for Culturally and Linguistically Appropriate Services is a tool that tests an organization‘s ability to:
• Develop an analytic framework for assessing cultural competence in health care delivery organizations.
• Identify specific indicators that can be used in connection with an evaluation framework.
• Assess the utility, feasibility and practical application of the framework and its indicators.
• Understand the relationship between culturally competent health services and client satisfaction/clinical outcomes/health status.

Definitions

Cultural safety: refers to what is felt or experienced by a patient when a health care provider communicates with the patient in a respectful, inclusive way, empowers the patient in decision-making and builds a health care relationship where the patient and provider work together as a team to ensure maximum effectiveness of care. Culturally safe encounters require that health care providers treat patient s with the understanding that not all individuals in a group act the same way or have the same beliefs (NAHO, 2003).
Cultural competence: is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations (U.S. Department of Health and Human Services, 2007).
Client-centred practice: Is based on enablement foundations and employs facilitation skills in a collaborative relationship with clients to advance a vision of health, well being, and justice through occupation. (Townsend & Polatajko, 2007) Client-centred occupational therapists demonstrate concern for clients, involve clients in decision-making, advocate with and for clients’ needs, and otherwise recognize clients’ experience and knowledge (CAOT, 2002).
Clients: In occupational therapy clients may be individuals, families, groups, communities, organizations, or populations who participate in occupational therapy services by direct referral or contract, or by other service and funding arrangements with a team, group, or agency that includes occupational therapy (Townsend & Polatajko, 2007).
Occupational therapy: the art and science of enabling engagement in everyday living, through occupation; of enabling people to perform the occupations that foster health and well-being; and of enabling a just and inclusive society so that all people may participate to their potential in the daily occupations of life (Townsend & Polatajko, 2007).

CAOT gratefully acknowledges and thanks NAHO for the support offered in the development of this preliminary draft position statement.

References

Canadian Association of Occupational Therapists. (2002).

Enabling occupation: An occupational therapy perspective (Rev. Ed.).Ottawa, ON: CAOT Publications ACE.
Canadian Association of Occupational Therapists (2007). Profile of occupational therapy practice in Canada. Ottawa, ON: CAOT Publications ACE.

National Aboriginal Health Organization. (2003). Analysis of aboriginal health careers education and training opportunities. Ottawa: National Aboriginal Health Organizations.

National Aboriginal Health Organizations. (2006). Fact Sheet: Cultural Safety. Retrieved from: www.naho.ca/english/documents/Culturalsafetyfactsheet.pdf

National Aboriginal Health Organization (2008). Cultural Safety and Competency and Safety: A Guide for Health Care Administrators, Providers, and Educators. Retrieved from: www.naho.ca/publications/culturalCompetency.pdf

Polachek, N.R. (1998). Cultural safety: A new concept in nursing people of different ethnicities. Journal of Advanced Nursing, 27, pp. 452–457.

Townsend, E. & Polatajko, H. (2007). Enabling Occupation II: Advancing an Occupational Therapy Vision for Advancing Health,Well-Being and Justice through Occupation.

U.S. Department of Health and Human Services. (2007). Other Definitions of Cultural Competence. Bureau of Health Professionals. Retrieved from http://bhpr.hrsa.gov/diversity/cultcomp.htm