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Cultural safety


Respect for patients and families

The wide spectrum of culture


  • Don't assume you know what your patients' needs are. Ask them how they want (or prefer) to be treated.
  • As with cultural differences, language barriers have the potential to increase the chance of misunderstanding.
A multigenerational Family photo

Cultures incorporate a mix of beliefs and behaviours through which people define themselves and conform to societal values. Language, customs, rules, values, and even products and institutions are all culture-specific.

People will conceptualize their illness and the required treatments differently, based on a number of factors including:

  • cultural background
  • spiritual beliefs
  • education

A person's response to recommendations for care will be shaped by:

  • the length of time the person has lived in Canada
  • the person's capacity to adapt

Even within one family, there may be significant differences in acculturation. Inter-generational tension between first and second generation immigrants and their families is not rare.

  • While members of an identifiable ethnic group may share common values, be careful to avoid stereotyping.

What is the difference between a generalization and a stereotype?

Whereas generalizations can be useful sources of information, stereotypes tend to be limiting and are often judgmental and negative.

  • A person's culture might guide behaviour in ways that are difficult for someone from a different background to understand.

Differences between cultures can be conceptualized in terms of opposing characteristics, with individuals falling somewhere along a continuous spectrum. The diagram illustrates several of these contrasting dimensions of culture: Individual vs. collectivist, Task vs. relationship, Direct vs. indirect, Equality vs. hierarchy, Future vs. past, Universal vs. situational, Verbal vs. nonverbal, Informal, vs. formal.

Dimensions of culture

Differences between cultures can be conceptualized in terms of opposing characteristics, with individuals falling somewhere along a continuous spectrum. For example, a person with a collectivist mindset is the opposite of an individualist. Similarly, some people apply rules universally while others change the application of rules based on situational information. In some cultures people communicate very directly while others are indirect. Finally, some cultures place a high value on hierarchy while others are more egalitarian.

With each case below, click on the scale to understand how patients' or physicians' cultural biases may influence their approach to healthcare and to see how differing views may conflict.

Case: Mitral valve replacement surgery

A 65-year-old female needs mitral valve replacement surgery.

Use the sliding scale below to see how her information needs might change based on her cultural background.


The patient coming from a hierarchical culture may expect and accept that physicians have more power and influence than she does. As such, she'll expect to be told what to do and to be supervised by the physician. She likely would not consider taking the initiative to ask questions or challenge the physician's opinion even though she may not understand or may inwardly disagree with the physician's suggestions.

A 65-year-old female needs mitral valve replacement surgery.

Use the sliding scale below to see how her information needs might change based on her cultural background.


Misunderstandings may occur if, for example, the physician is from a hierarchical culture and the patient is from a highly egalitarian culture. The physician who doesn't have an understanding of these differences in values may perceive the patient's assertions and questions as a lack of respect. Alternatively, a patient from a highly hierarchical culture who is used to being told what to do, may be at a loss to decide if a physician from an egalitarian culture asks them to choose from a variety of treatment options.

A 65-year-old female needs mitral valve replacement surgery.

Use the sliding scale below to see how her information needs might change based on her cultural background.


The patient coming from an egalitarian culture more likely has a sense of empowerment, is used to making decisions in an autonomous way, and may seek background information. This patient will expect to be asked about her preferences and expect to have the freedom to choose among treatment options. She will be quite comfortable disagreeing with her physician and will be more likely to complain if her expectations are not met.

HierarchicalEgalitarian

Case: Prescribing the wrong medication

In a moment of distraction, an emergency physician orders penicillin for a 13-year-old known penicillin-allergic female with a streptococcal throat infection. The patient is given the medication and develops anaphylactic shock which is treated.

Use the sliding scale below to see how the physician might respond to the adverse event and how willing she might be to disclose her role in the event, based on her cultural background.


The doctor coming from a collectivist culture likely cares deeply about belonging to a group and about feeling accepted and respected by that group. As a collectivist, she is an approval seeker who deeply cares about the image she projects to others. She might find it unthinkable to admit to having made a mistake, for fear of bringing dishonour to her family or cultural group.

In a moment of distraction, an emergency physician orders penicillin for a 13-year-old known penicillin-allergic female with a streptococcal throat infection. The patient is given the medication and develops anaphylactic shock which is treated.

Use the sliding scale below to see how the physician might respond to the adverse event and how willing she might be to disclose her role in the event, based on her cultural background.


A conflict may arise when a physician who is very concerned about maintaining the honour of his family decides not to disclose or to report an adverse event. While the physician's motivations may have been sincere, the Canadian medical-legal context requires that physicians be honest about adverse events. A patient who discovers that a physician willfully did not disclose an adverse event will likely be angry and lose faith in the physician. Similarly, if a court or medical regulatory authority (College) were to become aware of a physician's willful non-disclosure, they could take a very unfavourable view of the matter and issue sanctions or disciplinary measures.

In a moment of distraction, an emergency physician orders penicillin for a 13-year-old known penicillin-allergic female with a streptococcal throat infection. The patient is given the medication and develops anaphylactic shock which is treated.

Use the sliding scale below to see how the physician might respond to the adverse event and how willing she might be to disclose her role in the event, based on her cultural background.


The individualist doctor may be more motivated by self-improvement than the approval of others and does not see her achievements or failures as reflective of her family's but rather of her own self. As such, the individualist physician may not see disclosing adverse events as a reputation-threatening exercise, although she may nevertheless find it difficult.

CollectivistIndividualist

Case: Discussing a DNR order

You are admitting a 75-year-old terminally ill male to the hospital for dehydration secondary to his inability to adequately eat and drink at home. His illness is very advanced and you wish to discuss end-of-life care and resuscitation status with him. When you ask the patient and his family whether they would agree to a Do Not Resuscitate (DNR) status, they answer, "Maybe, but it is difficult."

Use the sliding scale below to see how understanding a person's culture and communication style can help you decipher that answer.


Families coming from a culture that values direct communication are likely comfortable telling you explicitly about their wants, needs, and expectations. Honesty and straight-forwardness are valued, as is the correct use of terms. Direct communicators may be perceived as blunt and have no difficulty saying "no."

You are admitting a 75-year-old terminally ill male to the hospital for dehydration secondary to his inability to adequately eat and drink at home. His illness is very advanced and you wish to discuss end-of-life care and resuscitation status with him. When you ask the patient and his family whether they would agree to a Do Not Resuscitate (DNR) status, they answer, "Maybe, but it is difficult."

Use the sliding scale below to see how understanding a person's culture and communication style can help you decipher that answer.


Physicians who are used to direct communication and are unaware of indirect communication modes may take such families' answer as an agreement or acquiescence when, in fact, what they really mean is to say "no." People who may normally be direct in their communication style may nevertheless become indirect when under stress.

You are admitting a 75-year-old terminally ill male to the hospital for dehydration secondary to his inability to adequately eat and drink at home. His illness is very advanced and you wish to discuss end-of-life care and resuscitation status with him. When you ask the patient and his family whether they would agree to a Do Not Resuscitate (DNR) status, they answer, "Maybe, but it is difficult."

Use the sliding scale below to see how understanding a person's culture and communication style can help you decipher that answer.


Families coming from a culture with an indirect communication style will likely highly value the maintenance of harmony and courtesy, in addition to honesty. Indirect communicators primarily want to avoid causing themselves or anyone else any embarrassment. Their wish to continue respecting others will lead them to express themselves by implying what they mean rather than by saying it directly. To an indirect communicator, the rudest answer to a question is "no," so consider framing your questions in a way that would not require a yes or no answer.

DirectIndirect

Case: A request from a new patient

A 64-year-old obese male with diabetes, congestive heart failure, a below knee amputation, hypercholesterolemia, hypertension, and chronic hepatitis books an appointment to see a new family physician. Although he already has a family physician, he lives too far away and the new physician's office is much closer. This physician's practice is so busy that she has been considering closing it to new patients but she has yet to do so. Upon reading the patient's history, the physician feels overwhelmed by the demanding medical needs of this patient and considers not accepting him into her practice.

Use the sliding scale below to see how the physician's decision may be influenced by her own cultural background.


The physician who was raised in a universal culture will likely believe there are over-arching guiding principles that apply to all situations and that can be used to determine the rightness or wrongness of specific beliefs and practices. As such, the physician, despite feeling overwhelmed at the thought of taking on this new patient, will nevertheless accept him into her practice because she realizes she cannot discriminate against him on the basis of his numerous medical needs.

A 64-year-old obese male with diabetes, congestive heart failure, a below knee amputation, hypercholesterolemia, hypertension, and chronic hepatitis books an appointment to see a new family physician. Although he already has a family physician, he lives too far away and the new physician's office is much closer. This physician's practice is so busy that she has been considering closing it to new patients but she has yet to do so. Upon reading the patient's history, the physician feels overwhelmed by the demanding medical needs of this patient and considers not accepting him into her practice.

Use the sliding scale below to see how the physician's decision may be influenced by her own cultural background.


The situationalist physician will argue that every situation is different and that absolute rules are inappropriate because they are too inflexible. In this case, the situationalist physician might argue that she cannot possibly take on a medically demanding patient because she had been planning on closing her practice anyway, or because it would be unfair to her other patients, or because the patient already has a family physician.

Universal Situational

Language barriers

Patient appears not to understand

A patient may seem to be fluent in the physician's language, but if it is the patient's second or third language there may be gaps in understanding. A trusted interpreter can help when appropriate, but physicians should be cautious in using friends or family members who may apply their own biases onto the discussion. For instance, a family member might be embarrassed to translate your questions about sexual activity, and the patient might be reluctant to reveal the truth.