Introduction

Providing safe and effective care that delivers the best possible outcomes for all people is a must for all healthcare professionals and is considered a right for all consumers of healthcare. The Australian Charter of Healthcare Rights developed by the Australian Commission on Safety and Quality in Health Care (ACSQHC) provides expectations for consumers engaging with healthcare. Consumers have the right to Access, Safety, Respect, Partnership, Information, Privacy, and the ability to give feedback. To read more about the Australian Charter of Healthcare Rights visit the Australian Commission on Safety and Quality in Health Care website: Australian Charter of Healthcare Rights. The following chapter will provide an overview of the National Safety and Quality Health Service standards developed to provide guidance on highly prevalent safety concerns within healthcare. It will explore the fundamentals of person-centred care and cultural safety, both vital components in ensuring the delivery of safe and effective care.

National Safety and Quality Health Service Standards

Developed by the ACSQHC in collaboration with relevant stakeholders are the National Safety and Quality Health Service Standards (NSQHS), which provide a consistent statement regarding the level of care consumers should expect from healthcare providers. These standards cover high prevalence safety concerns in healthcare and guide measures that assist in reducing adverse events (ACSQHC, 2021). The overall aim of the eight NSQHS standards is to promote high-quality safe care, effectively protecting the public from harm. The eight standards set by the commission are as follows:

Read more about the National Safety and Quality Health service standards on the Australian Commission on Safety and Quality in Health Care website: Safety and Quality.

People come to healthcare facilities expecting to be kept safe while receiving healthcare. According to the Australian Institute of Health and Welfare (AIHW, 2024), as of 2022–23 data showed adverse events treated in hospitals occurred in approximately 5.3% per 100 hospitalisations, this equates to one in 20 persons hospitalised. Data also revealed 82 sentinel events between 2020–2021. Sentinel events are events seen as wholly preventable that result in serious harm to or death of a patient (AIHW, 2024). The NSQHS are based around high prevalence safety concerns with the goal of reducing incidents within healthcare. High prevalence includes hospital-acquired infection (HAI), medication errors, communication breakdown, and missed detection of the deteriorating patient. Along with these, the standards also consider the harm that can be caused through pressure injury, falls, nutrition, mental health and cognitive impairment. Nurses must have a deep understanding of these high prevalence areas, why they occur and how they can be active participants in reducing and preventing occurrence. Each of these high prevalence areas will be discussed in their relevant chapters throughout this text.

Person-Centred Care

Person-centred care puts the individual at the heart of the healthcare experience, empowering them to actively participate in their own care and leading to better outcomes, increased satisfaction, and a truly collaborative partnership with their healthcare team.

Picture this: A person walks into a hospital or clinic, feeling vulnerable and uncertain about what lies ahead. Suddenly, they are greeted by a team of healthcare providers who prioritise their unique needs, preferences, and values above all else. They listen attentively to the person’s concerns, involve them in decision-making, and tailor their care to align with their individual goals. That is the power of person-centred care. Person-centred care focuses on treating the whole person, addressing not just physical symptoms but also emotional and social needs.

Fundamentals of Person-Centred Care

Person-centred care is widely recognised as a foundation to safe, high-quality healthcare. It is care that respects and responds to the preferences, needs and values of patients and consumers. (ACSQHC, 2011)

Person-centred care recognises the importance of understanding and respecting the unique needs, preferences, values, and beliefs of each individual patient. Person-centred care takes a holistic view of the patient, considering their physical, psychological, emotional, and social well-being. Nurses assess and address not only the patient’s medical condition but also their personal and psychosocial needs. This approach recognises that patients are unique individuals with their own life experiences, values, and beliefs that impact their health and healthcare decisions.

The Healthcare Team

Person-centred care involves a collaborative approach in which nurses work together with patients, their families, and other multidisciplinary team members. Shared decision-making empowers patients to actively participate in their care by providing information, discussing treatment options, and jointly deciding on the best course of action as a member of their own healthcare team. Nurses act as advocates, facilitating communication between patients and other healthcare professionals.

Although the patient is a member of their own healthcare team, person-centred care ultimately recognises patient autonomy, or the concept that patients have the right to make decisions about their own healthcare. Each patient is unique, with distinct physical, emotional, and social needs. Nurses should respect patients’ choices, values, and preferences and involve them in the decision-making process. This requires effective communication and active listening to understand and address the patient’s concerns. Nurses should strive to provide personalised care that considers the patient’s specific circumstances. This involves tailoring interventions, treatment plans, and education to meet the patient’s individual needs, cultural background, and beliefs.

Communication is crucial in person-centred care. Nurses should use clear and concise language, avoiding medical jargon, and ensure that patients understand the information provided. Active listening skills are essential to comprehend patients’ concerns, fears, and expectations. Open and honest communication builds trust and fosters a therapeutic relationship between the nurse and patient. Respecting privacy and maintaining confidentiality are also integral aspects of person-centred care.

Coordinated Healthcare

Person-centred care extends beyond individual encounters. Nurses should strive to provide continuity of care by promoting coordinated transitions between different healthcare settings and providers to improve patient outcomes. This includes clearly communicating patient information, practising proper handover procedures, and ensuring that patients feel supported throughout their healthcare journey. By promoting coordination and continuity, nurses help prevent fragmented and disjointed care.

Improved Patient Outcomes

When patients are actively involved in their care and their preferences are considered, it can lead to improved health outcomes. Patients who feel empowered and engaged are more likely to adhere to treatment plans, manage chronic conditions effectively, and achieve better overall health. The following image explores how person-centred care leads to improved patient outcomes. Click or tap on the ‘+’ buttons below for more information.

Improved Population Outcomes

Person-centred care is a healthcare approach that prioritises the individual patient’s needs, preferences, and values. While its primary focus is on the individual patient, person-centred care has a broader impact by improving the overall quality of care provided and promoting better health outcomes for the whole community. The following explores some ways in which person-centred care improves population outcomes.

Benefits of Person-Centred Care

There are multiple benefits of person-centred care, both for the patients and for other involved parties:

• It enhances the overall patient experience, leading to higher levels of satisfaction. Effective communication promotes trust and rapport between patients and healthcare providers. When patients feel respected, heard, and involved in their care, they are more likely to feel satisfied with the healthcare services they receive.
• It contributes to the job satisfaction of healthcare providers, including nurses. When nurses can establish meaningful connections with patients, collaborate in decision-making, and witness positive health outcomes, it can increase their professional fulfilment and motivation.
• It can lead to cost savings in the long run, although person-centred care requires an investment of time and resources. By actively involving patients in their care and tailoring interventions to their needs, unnecessary tests, procedures, and hospital readmissions may be reduced. Additionally, improved adherence to treatment plans can prevent complications and the need for more expensive interventions.

Culturally Safe Care

What is Culture?

Culture is a set of beliefs, attitudes, and practices shared by a group of people or community that is accepted, followed, and passed down to other members of the group. Cultural beliefs and practices bind group or community members together and help form a cohesive identity (Curtis et al, 2019; Young & Gou 2016). Culture has an enduring influence on a person’s view of the world, expressed through language and communication patterns, family connections and kinship, religion, cuisine, dress, and other customs and rituals (Campinha-Bacote, 2011). Culture is not static but is dynamic and ever-changing; it changes as members come into contact with beliefs from other cultures. Among cultures, subcultures also exist. A subculture is a smaller group of people within a culture, often based on a person’s occupation, hobbies, interests, or place of origin. People belonging to a subculture may identify with some, but not all, aspects of their larger “parent” culture. Members of the subculture share beliefs and commonalities that set them apart and do not always conform with those of the larger culture. The word “culture” may at times be interchanged with terms such as ethnicity, nationality, or race. However, culture is much more than a person’s nationality or ethnicity.

Culture can be expressed in a multitude of ways. Click or tap the ‘+’ buttons to explore the different ways in which culture can be expressed.

People typically belong to more than one culture simultaneously. These cultures overlap, intersect, and are woven together to create a person’s cultural identity. In other words, the many ways in which a person expresses their cultural identity are not separated but are closely intertwined, referred to as intersectionality.

Cultural Safety

Cultural safety is a framework for ensuring culturally safe care is at the heart of healthcare. Originating from the experiences of the Indigenous people of New Zealand, the concept of cultural safety was developed by nurse leader Irahapeti Ramsden and has fast become a model of care that is adapted for use across Australia, New Zealand, and Canada (Laverty et al., 2017). A commonly accepted definition of cultural safety from the Nursing Council of New Zealand (2005) is, in part, “the effective nursing practice of a person or family from another culture, and is determined by that person or family.” The definition further states that “unsafe cultural practice comprises any action which diminishes, demeans or disempowers the cultural identity and well-being of an individual.”

Many approaches have been developed and used in various manners in attempts to incorporate culturally safe care into healthcare delivery. These include frameworks such as cultural awareness, cultural respect, and cultural competence (Taylor & Guerin, 2018). Culturally safe practices continue to evolve, and along with that, we are seeing the development of other frameworks such as cultural capability and cultural humility (Taylor & Guerin, 2018). These concepts are often incorporated in a hybrid manner across services with terminology used interchangeably between them. Regardless of the model used within a health service, the goal remains the same in that all healthcare services provide care that produces the best possible outcomes using evidence-based, culturally safe person-centred care.

Cultural Safety in Nursing Practice

Australian nurses encounter people from a wide variety of cultural backgrounds. It is essential they can provide culturally safe care recognising the impact history and culture have on one’s health and wellbeing. This is mandated in the Nursing and Midwifery Standards of Practice where the board states registered nurses must understand colonisation effects on the cultural, social, and spiritual lives of Aboriginal and Torres Strait Islander peoples which contributes to significant health disparity in Australia (Nursing and Midwifery Board of Australia [NMBA], 2016). While Aboriginal and Torres Strait Islander peoples are a focus within this statement it is important to note that culturally safe care is intended for all cultures and includes differences in gender, religion, age, sexual orientation, ethnicity, disability, and socioeconomic status.

The Australian Institute of Health and Welfare (AIHW, 2023) have developed the Cultural safety in health care for Indigenous Australians: monitoring framework  that is aimed at measuring progress in achieving cultural safety within the Australian health system. This encourages a health system that respects Indigenous cultural values, strengths and differences and also addresses the issues of racism and inequity.

A healthcare service that delivers culturally safe care means that when planning and providing care, healthcare professionals consider their patients’ cultural needs (Moloney et al., 2023).  To become a culturally safe practitioner, a nurse needs to become culturally aware and develop cultural sensitivity and cultural respect.

Cultural Awareness

Gaining cultural awareness is one of the first steps in becoming a culturally safe practitioner. Put simply it is being aware that everyone is different (Taylor & Guerin, 2018). It is a deliberate, cognitive process in which healthcare providers become aware and appreciative of the values, beliefs, attitudes, practices, and problem-solving strategies of a person’s culture. Many cultural awareness programs developed tend to focus on the direct learning of other cultures, it is important to understand that cultural awareness is more than this. Cultural awareness importantly involves the nurse being aware of their own personal cultural values and understanding how these cultural practices may impact others. The nurse needs to be aware of any harmful prejudices, ethnocentric views, and attitudes that can impact the care provided. Cultural awareness goes beyond a simple awareness of the existence of other cultures and involves an interest, curiosity, and appreciation of other cultures. Becoming culturally aware requires the nurse to be critically self-aware, engaging in a lifelong process of self-evaluation and self-reflection.

Cultural Sensitivity

The next step in cultural safety is cultural sensitivity. To be culturally sensitive the nurse is sensitive and accepting of cultural practices and beliefs of other people. Cultural sensitivity is demonstrated when the nurse conveys nonjudgmental interest and respect through words and actions and demonstrates an understanding that some healthcare treatments may conflict with a person’s cultural beliefs (Cole, 2018). The nurse acknowledges differences, accepts them, and works towards appropriate alternatives that avoid these conflicts. Cultural sensitivity also acknowledges the damaging effects of stereotyping, prejudice, or biases on a person and their well-being. Nurses who fail to act with cultural sensitivity may be viewed as uncaring or inconsiderate, causing a breakdown in trust for the person and their family members. When a person experiences nursing care that contradicts their cultural beliefs, they may experience moral or ethical conflict, non-adherence, or emotional distress.

Cultural Respect

Cultural respect is defined as: “Recognition, protection and continued advancement of the inherent rights, cultures and traditions of Aboriginal and Torres Strait Islander people” (Australian Health Ministers’ Advisory Council, 2021). The importance of cultural safety and cultural respect is outlined in Australian government documents, such as:

• The Cultural Respect Framework 2016–2026 aimed at building a culturally respectful health system, which is achieved when the health system is accessible, responsive and safe for Aboriginal and Torres Strait Islander people, and cultural values, strengths and differences are respected.
• National Aboriginal and Torres Strait Islander Health Plan 2021–2031 seeks to embed the diversity of Aboriginal and Torres Strait Islander communities across Australia, including the diversity of cultures, languages, backgrounds, knowledge systems and beliefs.

Cultural Safety Principles

A healthcare service that fosters cultural safety recognises that all people are different, understands decolonisation, considers the impacts of power relationships, promotes reflective practices, and allows the determination of cultural safety to come from persons themselves.

This practice requires practitioners to be aware of their own cultural values, beliefs, attitudes and outlooks that consciously or unconsciously affect their behaviours. Certain behaviours can intentionally or unintentionally cause a person to feel accepted and safe, or rejected and unsafe. Additionally, cultural safety is a systemic outcome that requires organisations to review and reflect on their own policies, procedures, and practices in order to remove barriers to appropriate care (National Collaboration Centre for Indigenous Health in Canada, 2013).

According to Taylor and Guerin (2018), the underlying principles required for cultural safety include:

• Ability to reflect on own practice and develop awareness of own culture, values, and beliefs and how these may impact on care delivered
• Engage with the person, asking and not presuming to gain a full understanding of their beliefs, values, and preferences
• Be aware of and reduce power imbalances between self and person. Consider language, titles, and labels used
• Consider ongoing impacts and be involved in processes of decolonisation
• Ensure actions taken do not diminish, demean, or disempower others.

Culturally safe and respectful practice is not a new concept. Nurses and midwives are expected to engage with all people as individuals in a culturally safe and respectful way, foster open, honest and compassionate professional relationships, and adhere to their obligations about privacy and confidentiality. Nurses and midwives have always had a responsibility to provide care that contributes to the best possible outcome for the person they are caring for. They need to work in partnership with that person to do so (NMBA, 2018).

References

Australian Commission on Safety and Quality in Health Care. (2011). Patient-centred care: Improving quality and safety through partnerships with patients and consumers. https://www.safetyandquality.gov.au/publications-and-resources/resource-library/patient-centred-care-improving-quality-and-safety-through-partnerships-patients-and-consumers

Australian Commission on Safety and Quality in Health Care. (2021). National safety and quality health service standards (2nd ed.). https://www.safetyandquality.gov.au/sites/default/files/2021-05/national_safety_and_quality_health_service_nsqhs_standards_second_edition_-_updated_may_2021.pdf

Australian Health Ministers’ Advisory Council. (2016). Cultural respect framework 2016-2026. APO. https://apo.org.au/sites/default/files/resource-files/2016-01/apo-nid256721.pdf

Australian Institute of Health and Welfare. (2021). Cultural safety in health care for Indigenous Australians: Monitoring framework. Australian Government. https://www.aihw.gov.au/reports/indigenous-australians/cultural-safety-health-care-framework/contents/about

Australian Institute of Health and Welfare. (2024). Health system: Safety. Australian Government. https://www.aihw.gov.au/reports-data/australias-health-performance/australias-health-performance-framework/national/all-australia/safety/safety/2_2_3

Campinha-Bacote, J. (2011). Coming to know cultural competence: An evolutionary process. International Journal for Human Caring, 15(3), 42–48. https://doi.org/10.20467/1091-5710.15.3.42

Cole, N. L. (2018). How different cultural groups become more alike: Definition, overview and theories of assimilation. ThoughtCo. https://www.thoughtco.com/assimilation-definition-4149483

Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal for Equity in Health, 18(174). https://doi.org/10.1186/s12939-019-1082-3

Laverty, M., McDermott, D. R., & Calma, T. (2017). Embedding cultural safety in Australia’s main health care standards. Medical Journal of Australia, 207(1), 15–16. https://doi.org/10.5694/mja17.00328

Moloney, A., Stuart, L., Chen, Y., & Lin, F. (2023). Healthcare professionals’ cultural safety practices for indigenous peoples in the acute care setting – a scoping review. Contemporary Nurse, 59(4–5), 272–293. https://doi.org/10.1080/10376178.2023.2271576

National Collaborating Centre for Indigenous Health. (2013). Towards cultural safety for Métis: An introduction for health care providers. University of Northern British Columbia. https://www.nccih.ca/495/Towards_Cultural_Safety_for_M%C3%A9tis__An_introduction_for_health_care_providers.nccih?id=76

Nursing and Midwifery Board of Australia. (2016). Registered nurse standards of practice. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx

Nursing Council of New Zealand. (2005). Guidelines for cultural safety, the Treaty of Waitangi, and Maori health in nursing and midwifery education and practice.  https://www.nursingcouncil.org.nz/Public/Nursing/Standards_and_guidelines/NCNZ/nursing-section/Standards_and_guidelines_for_nurses.aspx

Taylor, K. & Guerin, P. (2018). Health care and Indigenous Australians: Cultural safety in practice (3rd ed). Palgrave Macmillan.

Young, S., & Guo, K. (2016). Cultural diversity training: The necessity for cultural competence for healthcare providers and in nursing practice. The Health Care Manager, 35(2), 94–102. https://doi.org/10.1097/hcm.0000000000000100

Chapter Attribution

This chapter has been adapted in part from:

Nursing fundamentals 2e by Open Resources for Nursing, Chippewa Valley Technical College, is used under a CC BY licence.

Patient-centered care in Clinical nursing skills (2024) by Christie Bowen et al., OpenStax, is used under a CC BY licence.