Evaluating the quality of medical care.

Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them. A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Māori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa – Māori Medical Practitioners Association (Te ORA) and consultation with Māori medical practitioners via Te ORA. Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the ‘taken for granted’ power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming ‘competent’ in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. 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. A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important.

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

Aim
The aim of this study was to report an analysis of the clinical learning environment concept.

Background
Nursing students are evaluated in clinical learning environments where skills and knowledge are applied to patient care. These environments affect achievement of learning outcomes, and have an impact on preparation for practice and student satisfaction with the nursing profession. Providing clarity of this concept for nursing education will assist in identifying antecedents, attributes and consequences affecting student transition to practice.

Design
The clinical learning environment was investigated using Walker and Avant's concept analysis method.

Data sources
A literature search was conducted using WorldCat, MEDLINE and CINAHL databases using the keywords clinical learning environment, clinical environment and clinical education. Articles reviewed were written in English and published in peer-reviewed journals between 1995–2014.

Methods
All data were analysed for recurring themes and terms to determine possible antecedents, attributes and consequences of this concept.

Results
The clinical learning environment contains four attribute characteristics affecting student learning experiences. These include: (1) the physical space; (2) psychosocial and interaction factors; (3) the organizational culture and (4) teaching and learning components. These attributes often determine achievement of learning outcomes and student self-confidence.

Conclusion
With better understanding of attributes comprising the clinical learning environment, nursing education programmes and healthcare agencies can collaborate to create meaningful clinical experiences and enhance student preparation for the professional nurse role.

The clinical learning environment in nursing education: a concept analysis

A peer learning intervention for nursing students in clinical practice education: A quasi-experimental study

Although nursing has a unique contribution to advancing social justice in health care practices and education, and although social justice has been claimed as a core value of nursing, there is little guidance regarding how to enact social justice in nursing practice and education. In this paper, we propose a critical antidiscriminatory pedagogy (CADP) for nursing as a promising path in this direction. We argue that because discrimination is inherent to the production and maintenance of inequities and injustices, adopting a CADP offers opportunities for students and practicing nurses to develop their capacity to counteract racism and other forms of individual and systemic discrimination in health care, and thus promote social justice. The CADP we propose has the following features: it is grounded in a critical intersectional perspective of discrimination, it aims at fostering transformative learning, and it involves a praxis-oriented critical consciousness. A CADP challenges the liberal individualist paradigm that dominates much of western-based health care, and the culturalist and racializing processes prevalent in nursing education. It also situates nursing practice as responsive to health inequities. Thus, a CADP is a promising way to translate social justice into nursing practice and education through transformative learning.

Drawing on antiracist approaches toward a critical antidiscriminatory pedagogy for nursing.

Cultural competence and cultural safety are essential knowledge in contemporary nursing care. Using a three-phase, mixed methods sequential triangulation design, this study examines the extent to which Anglophone Schools of Nursing in Canada have integrated cultural competence and/or cultural safety into the undergraduate nursing curricula. Factors that influence successful integration are identified through the lens of Donabedian's structure, process, and outcome model. Results suggest that several facilitating factors are present, such as leadership, partnerships and linkages, and educational supports for students. Of particular concern is the lack of policies to recruit and retain Aboriginal faculty, financial resources, and outcome evaluation indicators. A conceptual model of integration is offered to explain how Schools of Nursing function to support the implementation of these concepts into their curriculum. This study provides theoretical and practical implications for initiation and improvement of cultural competence and/or cultural safety integration strategies in Schools of Nursing.

Cultural competence and cultural safety in Canadian schools of nursing: a mixed methods study.

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Canadian Association of Schools of Nursing Association canadienne des écoles de sciences infirmières

Educational preparation of health professionals for Palliative and End of Life Care (PEOLC) is inadequate, and nurses are no exception. In 2004, the Canadian Association of Schools of Nursing struck a Task Force to develop PEOLC competencies to address this issue. The development of national PEOLC nursing competencies involved a multi-step, emergent, interactive, and iterative process. An overarching principle guiding this process was building national consensus about the essential PEOLC specific competencies for nurses among experts in this field while simultaneously generating, revising, and refining them. There have been three stages in this iterative, multi-step process: 1) Generating a preliminary set of competencies, 2) Building a national consensus among educators and experts in the field on PEOLC specific competencies for nurses, and 3) Refining the consensus based competencies for curriculum development. Ongoing follow up work for this project is focusing on the integration of these competencies into nursing curricula.

Cynthia Baker

Papers

Cultural competence and cultural safety in Canadian schools of nursing: a mixed methods study.

Canadian Association of Schools of Nursing Association canadienne des écoles de sciences infirmières

Developing palliative care competencies for the education of entry level baccalaureate prepared Canadian nurses.