Why cultural safety rather than cultural competency is required to achieve health equitya literature review and recommended definition

Elana Curtis, Rhys Jones, David Tipene‐Leach, Curtis Walker, Belinda Loring, Sarah‐Jane Paine, Papaarangi Reid•View original

OverviewBalancedalloy voice

Let's start with a hard truth. In Aotearoa New Zealand, Māori still die earlier and receive poorer care than non-Māori. The headline number lands like a stone: from 2010 to 2012, life expectancy at birth for Māori was seven point three years lower than for non-Māori. Behind that figure is a pattern—gaps in access, gaps in quality, and the too-familiar experience of not being listened to or properly explained to in clinical encounters. If you're asking why, Curtis and colleagues would tell you to look past the idea that this is a problem of "cultural knowledge" alone. The drivers run deeper: unequal power, institutional racism, and the social conditions that shape who gets what care. That brings us to a deceptively simple question with big consequences: what should health systems actually train for and hold themselves to? For years, the go-to answer was cultural competency. Learn about other cultures, build a skill set, tick the box. It sounded doable. It promised measurement. But promises can mislead when they're pointed at the wrong target. The thrust of Curtis and colleagues' work is that the frame you choose—competency versus safety—changes everything about how you respond to inequity. A quick bit of history sets the stage. Cultural competency took off in the 1980s and 1990s. A widely cited touchstone is Cross and colleagues' monograph from 1989, which described competence as a set of congruent behaviors, attitudes, and policies that enable effective work in cross-cultural situations. They pictured it as a continuum, from destructiveness at one end to proficiency at the other. That continuum gave policymakers and educators a roadmap. You could teach content. You could assess attitudes. You could say where a clinician sat on the line. But here's the catch. When you make culture into a checklist, you turn a living, shifting relationship into an exam. The literature is full of this critique. Competency often hardens into a static endpoint—something you complete and then move on from. Worse, it can become a course in "the Other," a kind of cargo-cult knowledge about groups that flattens differences and slides into stereotype. You accumulate facts about someone else's culture while never asking how your own assumptions, and the system you work in, shape the encounter. And that's the deeper objection. As van Ryn and colleagues have shown, racism doesn't just sit outside the clinic; it gets into clinician cognition, behavior, and decision making. So even well-intentioned providers can reproduce inequities if the frame stays fixed on knowledge of others and ignores power. New Zealand wrote a different chapter. In the 1990s, Dr. Irihapeti Ramsden and Māori nurses advanced the idea of cultural safety. The pivot was radical in its simplicity: safety isn't something the clinician declares; it's judged by the patient and their community. And it's not a flavor of etiquette. It's a call to examine your own culture, your profession's culture, and the structures that distribute power in care. The Nursing Council of New Zealand made cultural safety a requirement for nursing and midwifery education in 1992. That move didn't magically close gaps—remember the seven point three years—but it reframed the goal. Curtis and colleagues set out to push that reframing into the center of policy and practice. Their strategy was methodical. First, they ran an international literature review—no year limits, major medical, education, and social science databases, plus grey literature—to map how cultural competency and safety have been defined and used. That search pulled in fifty-one articles, and opportunistic searching added eight more, for fifty-nine pieces spanning 1989 to 2018, with sources from the United States, Canada, Australia, New Zealand, Taiwan, and Sweden. Second, they grounded the analysis in the New Zealand regulatory world—what the Medical Council of New Zealand had on the books, what standards were in place, where obligations sat. Third, they convened a national Symposium on Cultural Competence and Māori Health with the Medical Council and Te Ohu Rata o Aotearoa, the Māori Medical Practitioners Association. Those deliberations, alongside consultation with Māori doctors through Te ORA, pulled Indigenous expertise and priorities to the front of the table, where they belong. They were explicit about their stance. The work sits within an Indigenous research positioning aligned with Kaupapa Māori approaches: transformative, under Māori control where possible, oriented to benefit Māori, and aimed squarely at challenging structures of power and racism. That's not window dressing. It sets the lens. If inequities are produced by systems, then the only honest response is to examine and change those systems, not just the content of a training module. And it pairs naturally with the van Ryn frame: stop treating "race" as a patient attribute that explains outcomes; look at how racism shapes provider behavior and clinical decisions. So what, concretely, did they argue should change? Start with the definition. In their synthesis, cultural safety requires both individual professionals and their organizations to examine themselves—their biases, assumptions, and structures—and to engage in ongoing, accountable self-reflection. The test of success isn't what the clinician knows about someone else's culture. It's whether patients and communities experience care as safe, and whether the gaps in outcomes close. Safety, in other words, is measured by progress toward equity. That shift has teeth only if it's systemic. Curtis and colleagues stress that regulatory and educational bodies have too often located responsibility at the level of the lone provider and a competency checklist. That's not where power sits. It sits in governance, in clinical environments, in funding flows, in who gets to define quality. So they call for cultural safety to become an organizational obligation. Mandate engagement with cultural safety in vocational training and continuing professional development. Build evidence of cultural safety into accreditation and recertification. Require that training moves past awareness to explicitly confront power and privilege, with structured opportunities for reflective practice. And create feedback loops that center patient and community voice, because safety isn't yours to declare. If you're wondering how to know whether any of this is working, the answer is both straightforward and demanding. Tie metrics to equity. Monitor inequities in the workforce and in outcomes, not just participation in workshops. Make those data part of routine quality review. The headline number might be life expectancy, but equity shows up in many places: access, timeliness, communication, trust. The paper doesn't try to solve the entire measurement challenge—Curtis and colleagues acknowledge that developing the best training and monitoring tools sits beyond the scope of their review and needs further work—but it is unambiguous about the standard. If safety is real, inequities narrow. There's a practical start point they recommend: organizational self-review. Not a one-off audit, but an honest look at where policies, practices, and environments create or reduce risk for different groups. From that, build an action plan. Require cultural safety training and performance monitoring not just for frontline staff, but for supervisors and assessors. And be clear that cultural safety is an independent obligation. It relates to expectations for competence in ethnic or Indigenous health, but it isn't reducible to that slice of a curriculum. It's about how the whole system works. Let's pause and connect the dots back to the lived experience that motivates all of this. Māori patients report poorer explanations and a sense that clinicians aren't listening as well as they do with non-Māori. That's not a soft outcome; communication shapes diagnosis, adherence, and trust. If a "competency" approach produces a clinician who can list three facts about tikanga Māori but still dominates the conversation, interrupts, or defaults to biased decision rules, the inequity stays put. A safety approach asks the harder questions: Who speaks? Who decides? Whose definitions of quality count in this clinic or ward? And it requires organizations to change the conditions that answer those questions. The review also traces how these ideas evolved internationally. In many places, regulators have started to build elements of safety into licensing, accreditation, and in-service training. That's promising, but Curtis and colleagues are careful to say the job isn't to sprinkle safety language into existing forms. It's to align policies, accreditation standards, training environments, and everyday practices so that equity is the measurable payoff. Think of it less as a new module and more as a re-engineering of what counts as good care. You might be wondering whether there's consensus on what cultural safety actually is. The short answer is: there's movement, and there's debate. Some writers cast safety as a complete paradigm shift, a break from competence toward power analysis and social justice. Others see it as a continuing process of reflexivity that deepens over time. Curtis and colleagues don't try to adjudicate the philosophy. They emphasize alignment and accountability. However you narrate the shift, make sure your governance, training, and metrics point to equity, and make sure patients and communities get to affirm whether care feels safe. A word on scope and rigor. This wasn't a random sample meta-analysis designed to compute pooled effect sizes; it was a purposive review to clarify concepts and inform policy for the Medical Council and Te ORA. That's why the team paired the literature with a national symposium and consultation under a Kaupapa Māori frame. The value is in the synthesis and the practical levers it identifies: redefine success, move responsibility up to organizations, build in patient voice, tie monitoring to outcomes. There's plenty of detailed tool-building still to do. But the direction of travel is clear. So what does this mean if you're a clinician, a manager, or a regulator listening on your commute? It means shifting your mental model. Cultural competency asks, "What do I know about them?" Cultural safety asks, "How do my culture and my system shape this care, and how will I know—because patients and communities tell me and because the numbers move—that it's safe?" One is a checklist. The other is a commitment. And it means being willing to be measured by the thing that matters. Not attendance certificates. Equity. If the seven point three-year gap shrinks, if Māori report better communication and trust, if access and outcomes converge, then the system is getting safer. If not, then whatever we're calling "competent" isn't cutting it. The close on Curtis and colleagues' case is both pragmatic and principled. Pragmatic because they lay out concrete steps—mandate engagement, embed requirements in accreditation and certification, monitor inequities, start with organizational self-review, and make training transformative rather than performative. Principled because they center Indigenous voices, define safety by patients and communities, and refuse to treat inequity as a problem of cultural trivia. The measure is equity. The work is systemic. The invitation, really, is to trade the comfort of a checklist for the harder, better work of making care safe in the only way that counts—because the people receiving it say it is, and because their health shows it.

Behind that figure is a pattern—gaps in access, gaps in quality, and the too-familiar experience of not being listened to or properly explained to in clinical encounters. If you're asking why, Curtis and colleagues would tell you to look past the idea that this is a problem of "cultural knowledge" alone. The drivers run deeper: unequal power, institutional racism, and the social conditions that shape who gets what care.

That brings us to a deceptively simple question with big consequences: what should health systems actually train for and hold themselves to? For years, the go-to answer was cultural competency. Learn about other cultures, build a skill set, tick the box.

It sounded doable. It promised measurement. But promises can mislead when they're pointed at the wrong target.

The thrust of Curtis and colleagues' work is that the frame you choose—competency versus safety—changes everything about how you respond to inequity.

A quick bit of history sets the stage. Cultural competency took off in the 1980s and 1990s. A widely cited touchstone is Cross and colleagues' monograph from 1989, which described competence as a set of congruent behaviors, attitudes, and policies that enable effective work in cross-cultural situations.

They pictured it as a continuum, from destructiveness at one end to proficiency at the other. That continuum gave policymakers and educators a roadmap. You could teach content. You could assess attitudes. You could say where a clinician sat on the line.

But here's the catch. When you make culture into a checklist, you turn a living, shifting relationship into an exam. The literature is full of this critique.

Competency often hardens into a static endpoint—something you complete and then move on from. Worse, it can become a course in "the Other," a kind of cargo-cult knowledge about groups that flattens differences and slides into stereotype. You accumulate facts about someone else's culture while never asking how your own assumptions, and the system you work in, shape the encounter.

And that's the deeper objection. As van Ryn and colleagues have shown, racism doesn't just sit outside the clinic; it gets into clinician cognition, behavior, and decision making. So even well-intentioned providers can reproduce inequities if the frame stays fixed on knowledge of others and ignores power.

New Zealand wrote a different chapter. In the 1990s, Dr. Irihapeti Ramsden and Māori nurses advanced the idea of cultural safety.

The pivot was radical in its simplicity: safety isn't something the clinician declares; it's judged by the patient and their community. And it's not a flavor of etiquette. It's a call to examine your own culture, your profession's culture, and the structures that distribute power in care.

The Nursing Council of New Zealand made cultural safety a requirement for nursing and midwifery education in 1992. That move didn't magically close gaps—remember the seven point three years—but it reframed the goal.

Curtis and colleagues set out to push that reframing into the center of policy and practice. Their strategy was methodical. First, they ran an international literature review—no year limits, major medical, education, and social science databases, plus grey literature—to map how cultural competency and safety have been defined and used.

That search pulled in fifty-one articles, and opportunistic searching added eight more, for fifty-nine pieces spanning 1989 to 2018, with sources from the United States, Canada, Australia, New Zealand, Taiwan, and Sweden. Second, they grounded the analysis in the New Zealand regulatory world—what the Medical Council of New Zealand had on the books, what standards were in place, where obligations sat. Third, they convened a national Symposium on Cultural Competence and Māori Health with the Medical Council and Te Ohu Rata o Aotearoa, the Māori Medical Practitioners Association.

Those deliberations, alongside consultation with Māori doctors through Te ORA, pulled Indigenous expertise and priorities to the front of the table, where they belong.

They were explicit about their stance. The work sits within an Indigenous research positioning aligned with Kaupapa Māori approaches: transformative, under Māori control where possible, oriented to benefit Māori, and aimed squarely at challenging structures of power and racism. That's not window dressing.

It sets the lens. If inequities are produced by systems, then the only honest response is to examine and change those systems, not just the content of a training module. And it pairs naturally with the van Ryn frame: stop treating "race" as a patient attribute that explains outcomes; look at how racism shapes provider behavior and clinical decisions.

So what, concretely, did they argue should change? Start with the definition. In their synthesis, cultural safety requires both individual professionals and their organizations to examine themselves—their biases, assumptions, and structures—and to engage in ongoing, accountable self-reflection.

The test of success isn't what the clinician knows about someone else's culture. It's whether patients and communities experience care as safe, and whether the gaps in outcomes close. Safety, in other words, is measured by progress toward equity.

That shift has teeth only if it's systemic. Curtis and colleagues stress that regulatory and educational bodies have too often located responsibility at the level of the lone provider and a competency checklist. That's not where power sits.

It sits in governance, in clinical environments, in funding flows, in who gets to define quality. So they call for cultural safety to become an organizational obligation. Mandate engagement with cultural safety in vocational training and continuing professional development.

Build evidence of cultural safety into accreditation and recertification. Require that training moves past awareness to explicitly confront power and privilege, with structured opportunities for reflective practice. And create feedback loops that center patient and community voice, because safety isn't yours to declare.

If you're wondering how to know whether any of this is working, the answer is both straightforward and demanding. Tie metrics to equity. Monitor inequities in the workforce and in outcomes, not just participation in workshops.

Make those data part of routine quality review. The headline number might be life expectancy, but equity shows up in many places: access, timeliness, communication, trust. The paper doesn't try to solve the entire measurement challenge—Curtis and colleagues acknowledge that developing the best training and monitoring tools sits beyond the scope of their review and needs further work—but it is unambiguous about the standard. If safety is real, inequities narrow.

There's a practical start point they recommend: organizational self-review. Not a one-off audit, but an honest look at where policies, practices, and environments create or reduce risk for different groups. From that, build an action plan.

Require cultural safety training and performance monitoring not just for frontline staff, but for supervisors and assessors. And be clear that cultural safety is an independent obligation. It relates to expectations for competence in ethnic or Indigenous health, but it isn't reducible to that slice of a curriculum. It's about how the whole system works.

Let's pause and connect the dots back to the lived experience that motivates all of this. Māori patients report poorer explanations and a sense that clinicians aren't listening as well as they do with non-Māori. That's not a soft outcome; communication shapes diagnosis, adherence, and trust.

If a "competency" approach produces a clinician who can list three facts about tikanga Māori but still dominates the conversation, interrupts, or defaults to biased decision rules, the inequity stays put. A safety approach asks the harder questions: Who speaks? Who decides?

Whose definitions of quality count in this clinic or ward? And it requires organizations to change the conditions that answer those questions.

The review also traces how these ideas evolved internationally. In many places, regulators have started to build elements of safety into licensing, accreditation, and in-service training. That's promising, but Curtis and colleagues are careful to say the job isn't to sprinkle safety language into existing forms.

It's to align policies, accreditation standards, training environments, and everyday practices so that equity is the measurable payoff. Think of it less as a new module and more as a re-engineering of what counts as good care.

You might be wondering whether there's consensus on what cultural safety actually is. The short answer is: there's movement, and there's debate. Some writers cast safety as a complete paradigm shift, a break from competence toward power analysis and social justice.

Others see it as a continuing process of reflexivity that deepens over time. Curtis and colleagues don't try to adjudicate the philosophy. They emphasize alignment and accountability.

However you narrate the shift, make sure your governance, training, and metrics point to equity, and make sure patients and communities get to affirm whether care feels safe.

A word on scope and rigor. This wasn't a random sample meta-analysis designed to compute pooled effect sizes; it was a purposive review to clarify concepts and inform policy for the Medical Council and Te ORA. That's why the team paired the literature with a national symposium and consultation under a Kaupapa Māori frame.

The value is in the synthesis and the practical levers it identifies: redefine success, move responsibility up to organizations, build in patient voice, tie monitoring to outcomes. There's plenty of detailed tool-building still to do. But the direction of travel is clear.

So what does this mean if you're a clinician, a manager, or a regulator listening on your commute? It means shifting your mental model. Cultural competency asks, "What do I know about them?" Cultural safety asks, "How do my culture and my system shape this care, and how will I know—because patients and communities tell me and because the numbers move—that it's safe?" One is a checklist. The other is a commitment.

And it means being willing to be measured by the thing that matters. Not attendance certificates. Equity.

If the seven point three-year gap shrinks, if Māori report better communication and trust, if access and outcomes converge, then the system is getting safer. If not, then whatever we're calling "competent" isn't cutting it.

The close on Curtis and colleagues' case is both pragmatic and principled. Pragmatic because they lay out concrete steps—mandate engagement, embed requirements in accreditation and certification, monitor inequities, start with organizational self-review, and make training transformative rather than performative. Principled because they center Indigenous voices, define safety by patients and communities, and refuse to treat inequity as a problem of cultural trivia.

The measure is equity. The work is systemic. The invitation, really, is to trade the comfort of a checklist for the harder, better work of making care safe in the only way that counts—because the people receiving it say it is, and because their health shows it.

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