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Abstract
Aboriginal and Torres Strait Islander people in Australia face disparities in accessing culturally safe and appropriate health services. While current cultural safety and responsiveness frameworks set standards for improving healthcare practices, ensuring accountability and sustainability of changes, necessitates robust mechanisms for auditing and monitoring progress. This study examined existing cultural safety audit tools, and facilitators and barriers to implementation, in the context of providing culturally safe and responsive healthcare services with Aboriginal and Torres Strait Islander people. This will assist organisations, interested in developing tools, to assess culturally responsive practice. A scoping review was undertaken using Medline, Scopus, CINAHL, Informit and PsychInfo databases. Articles were included if they described an audit tool used for healthcare practices with Aboriginal and Torres Strait Islander people. Selected tools were evaluated based on alignment with the six capabilities of the Indigenous Allied Health Australia (IAHA) Cultural Responsiveness in Action Framework. Implementation barriers and facilitators were identified. 15 papers were included. Audit tools varied in length, terminology, domains assessed and whether they had been validated or evaluated. Seven papers reported strong reliability and validity of the tools, and one reported tool evaluation. Implementation facilitators included: tool comprehensiveness and structure; effective communication; clear organisational responsibility for implementation; commitment to prioritising cultural competence; and established accountability mechanisms. Barriers included: the tool being time-consuming and inflexible; responsibility for implementation falling on a small team or single staff member; deprioritising tool use; and lack of accountability for implementation. Two of the six IAHA capabilities (respect for the centrality of cultures and inclusive engagement) were strongly reflected in the tools. The limited tool evaluation highlights the need for further research to determine implementation effectiveness and sustainability. Action-oriented tools, which comprehensively reflect all cultural responsiveness capabilities, are lacking and further research is needed to progress meaningful change within the healthcare system.
- Review
- Public Health
- Health systems evaluation
- Health systems
- Health services research
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Cultural safety and cultural responsiveness are proactive antiracism approaches that contribute to advancing Aboriginal and Torres Strait Islander peoples self-determination and health equity reform agenda in Australia and the antiracism conventions of the United Nations.
Individuals and organisations are the drivers of transformational processes in creating culturally safe and responsive systems.
To support practice transformation, active accountability and sustainability of mechanisms, such as audit tools, that assess cultural responsiveness are critical.
WHAT THIS STUDY ADDS
Individual and organisational transformation may be better facilitated with use of tools that incorporate all cultural responsiveness capabilities and reflect Aboriginal and Torres Strait Islander ways of knowing, being and doing.
Nursing and midwifery, in comparison to other mainstream healthcare practices, are leading the way in development and implementation of mechanisms to support culturally responsive practice.
Despite the abundance of existing audit tools, these tools require robust evaluation and opportunity for self-reflection and client feedback mechanisms that enable accountability and sustainability of genuine cultural responsiveness.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
A tool, which measures and monitors all areas of cultural responsiveness in practice, can support both non-Indigenous and Aboriginal and Torres Strait Islander healthcare professionals in dispelling the myth surrounding certain cultural responsiveness capabilities and the ease in which they can be applied in individual and organisational practice.
Well-developed and well-implemented tools will support healthcare practitioners in effectively confronting and reforming systemic racism by providing individuals and organisations with skills required to contribute towards dismantling systems of oppression.
Cultural responsiveness is everyone’s responsibility—it is a lifelong commitment to unlearning and relearning that enables a shift in current ways of knowing, being and doing for individual accountability in improving Aboriginal and Torres Strait Islander health outcomes.
Introduction
All First Nations people should have the reasonable expectation of accessing culturally safe healthcare where individuals feel they can use services that support agency over individual and community health. Such care should be free of racism and consistently effective, regardless of where it is sought.1 The complexities and current poor outcomes of Aboriginal and Torres Strait Islander health demand prioritisation from all levels of government. One major barrier to progressing health priorities is systemic racism within Australia’s healthcare system, requiring significant reforms for systemic change if health inequities are to be redressed.2 For systemic change to occur, effective approaches to individual and organisational level practice that centre on dismantling systems of oppression, including eliminating racism, are required. Cultural safety processes are a lifelong process of teaching and learning on an individual and organisational level. Dismantling of oppressive systems of beliefs and practice that happen at the individual and organisational level should culminate in implementation of cultural safety practices within healthcare services for Aboriginal and Torres Strait Islander people. Cultural safety and cultural responsiveness are proactive antiracism approaches that align with the growing priority for Aboriginal and Torres Strait Islander peoples to drive the health equity reform agenda in Australia (eg, Queensland’s Health Equity Framework 20213) and the antiracism conventions regarding healthcare, among other contexts, such as those of the United Nations.
The terms ‘cultural competence’, ‘cultural capability’, ‘cultural proficiency’, ‘cultural safety’, ‘cultural security’ and ‘cultural responsiveness’ are often used interchangeably limiting the ability to build an evidence base on a shared understanding of terminology.4 5 While these terms are used interchangeably, they are distinct from each other.5 Specifically, cultural safety, which focuses on the subjective experience of First Nations recipients of healthcare practice, originates from an Indigenous knowledge system that confronts and attempts to reform the current legacy of colonial health systems that privileges the dominant culture.6 7 Cultural safety is an ongoing learning process of self-reflection, through one’s own cultural self-awareness, sensitivity in acknowledging the difference between self and the other and how this process informs and impacts on practitioner client interactions and service delivery.5 Indigenous Allied Health Australia (IAHA) builds on the concept of cultural safety to include a cultural responsiveness approach—an innately transformative method ‘by which we achieve and maintain cultural safety’.5 A culturally safe workforce, in which shared understandings of self and one another are clear, is foundational to a sustainable approach to practice. For this review, we consider cultural safety and cultural responsiveness in action together to accurately reflect how healthcare systems can be transformed.
The mutuality of cultural safety and cultural responsiveness, which are informed by Aboriginal and Torres Strait Islander ways of knowing, being and doing5 within practice, are critical levers that can assist organisations to strategise the implementation of key capabilities and principles to create and provide a culturally safe healthcare service. IAHA’s Cultural Responsiveness in Action Framework identifies six key interconnected capabilities—respect for the centrality of cultures, self-awareness, proactivity, inclusive engagement, leadership, and responsibility and accountability. These capabilities are operative instruments for practitioners and organisations alike in enabling a cultural responsiveness initiative that positions individuals and organisations as the drivers of transformational processes in creating culturally safe and responsive systems.
Transformation processes require active accountability and sustainability of mechanisms to support operationalisation of practice change. Audit tools are instruments of quality and designed for accountability in healthcare practice providing a structure for healthcare workers and organisations to use in designing and monitoring change.8 Numerous audit tools exist in Australia; however, it is unclear if these tools are effective in assessing and monitoring cultural safety and culturally responsive practice in the organisations and the contexts in which they are being implemented.
While some tools exist for use by those working with Aboriginal and Torres Strait Islander people in healthcare settings (eg, The Cultural Survey Scale, which measures cultural safety from a service users’ perspective,6 New South Wales Health Services Aboriginal Cultural Engagement Self-Assessment Tool9), to the best of our knowledge, no studies have been conducted to examine the barriers and/or facilitators to their implementation. Having a clearer understanding of existing audit tools, their characteristics and their effectiveness (or lack thereof) provides valuable evidence for identification of best practice examples and potential gaps in current practices.
IAHA are interested in developing an audit tool that can be used to assess how well individual and organisational practice reflects the six capabilities articulated in their Cultural Responsiveness in Action Framework (described below). Therefore, in this review, we aim to identify and examine existing audit tools and their implementation barriers and/or facilitators, for cultural safety and culturally responsive healthcare practices with Aboriginal and Torres Strait Islander people.
Scoping review questions
What are the features of existing audit tools for culturally safe and responsive healthcare practices used by those working with Aboriginal and Torres Strait Islander people?
What are the barriers for the effective implementation of existing audit tools?
What are the facilitators for the effective implementation of existing audit tools?
How do the features of existing audit tools align with the six capabilities in IAHA’s Cultural Responsiveness in Action Framework?
Methods
Design
The review was guided by Arksey and O’Malley’s10 six-step framework: identifying the research question; identifying relevant studies; study selection; charting the data; collating, summarising and reporting the results; consultation.10 In line with Munn et al’s11 indications and purposes for undertaking a scoping review, this methodology was chosen to allow identification of the range of research available on the existence of, characteristics and application of culturally safe audit tools, to examine the key components of these tools and identify limitations in the tools.11
The research project and questions were identified and developed in partnership with IAHA, who are national leaders in Aboriginal and Torres Strait Islander workforce development, including the support of individuals and organisations working with Aboriginal and Torres Strait Islander people.
Search strategy
In consultation with a librarian, a systematic search was performed between March 2022 and September 2023 using five databases: Medline, Scopus, CINAHL, Informit and PsychInfo. Search terms were divided according to the population, intervention, comparison and outcomes framework, detailed in table 1.
PICO search strategy
Study selection
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews protocol was followed.12 The lead author (JM) conducted database searches, removed duplicates and screened titles and abstracts. Eligible full texts were uploaded to Clarivate Endnote and screened using the inclusion and exclusion criteria (table 2).
Inclusion and exclusion criteria
Data extraction and quality assessment
Data was extracted from the reviewed articles that described: study aim, study design and methods, tool, participants/tool users and setting, tool characteristics, evaluation and tool validation, and key findings. Included publications were verified on title, abstract and full text by a second researcher to ensure their eligibility. Both researchers also hand-searched the reference lists of included studies. Data was extracted and characteristics of tools were mapped and analysed against the six IAHA Cultural Responsiveness in Action Framework capabilities (respect for the centrality of cultures, self-awareness, proactivity, inclusive engagement, leadership, responsibility and accountability). Mapping was done by each coauthor and was discussed over a series of meetings that aimed to address any concerns and reach consensus on alignment between tool characteristics and IAHA capabilities. As the focus of this scoping review was on characteristics of audit tools, no evaluation of methodological quality was undertaken.
Results
In total, 688 publications were identified via the search strategy: CINAHL (172), Informit (86), Medline (101), Scopus (88), PsychInfo (163). After removal of 100 duplicates, 522 papers remained. Following title and abstract screening, 68 papers remained. Full texts screening resulted in 15 papers meeting the inclusion criteria and were included in the review. The PRISMA flow diagram outlines the search results (figure 1). Of the 15 included publications, 8 were quantitative studies, 3 were qualitative studies, 1 was a literature review, 1 was a discussion article and 1 was a mixed-method study.
PRISMA flow diagram of search strategy. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Summary of included articles
The articles included in the review are summarised in table 3. All 15 studies included were published since 2006, with 12 published after 2017. All studies were conducted in Australia: national focus (n=6; 13–17, 25) or at a state level—New South Wales (n=1; 6), Queensland (n=4; 18–21), Western Australia (n=3; 22–24) and Victoria (n=1; 8). Participant sample sizes ranged from 10 participants in a small-scale regional pilot study to 1151 participants for a cross-sectional survey of undergraduate healthcare students and health professionals. Five articles used a healthcare student sample, specifically midwifery and nursing undergraduate students. Four of the other articles recruited practicing nurses and midwives from various maternity services. Participants and healthcare settings of the other six studies varied and included: social work, general practice, speech pathology, mental health services, rural public health and community services, and hospital and programme attendees. Through the literature search, we explored features of audit tools and the barriers and facilitators for their implementation.
Study characteristics
Features of identified audit tools
12 different audit tools were reported in the included articles and included: the Cultural Competency Scale,13 The Organisational Cultural Competence Assessment Tool,14 Ganngaleh nga Yagaleh (GY) cultural safety assessment tool (previous named the Cultural Capability Measurement Tool) (n=4; 14, 19–21), The Cultural Safety Survey Scale,6 Awareness of Cultural Safety Scale-Revised,15 ‘Meeting people in their own reality’ guidelines,16 Koolin Balit Aboriginal Health Cultural Competence (KB-AHCC) audit tool,8 self-audit of knowledge and skills on Indigenous perspectives and health,17 checklist for culturally competent general practitioners (GPs),18 cultural responsiveness audit tool,19 best practice framework20 and the Continuous Improvement Cultural Responsiveness Tool (CICRT)—audit tool.21 Four studies described the same tool (GY), but each study used a modified or updated version, and validated the tool in different ways, thus, these studies are summarised independently in table 3.
Audit tools varied in length, terms used, domains assessed and whether they had been validated or evaluated. The tools ranged from assessing 4 indicators of cultural responsiveness to 36 self-rating questions of cultural capability. Varied terms used in articles included: cultural competence (n=5; 8, 13, 17, 18, 22), cultural safety (n=7; 6, 14–16, 19–21), cultural capability (n=4; 14, 19–21), cultural responsiveness (n=2; 23, 25) and cultural sensitivity (n=1; 24). Of the 14 included articles, 6 articles examined reliability and validity of the tools, of which face (n=2; 14, 21), construct (n=6; 6, 13, 14, 19–21), concurrent (n=1; 20) and content (n=6; 6, 13, 14, 19–21) validity were assessed. All tools tested, demonstrated strong reliability and validity. Only one article reported on a qualitative evaluation of the audit tool (KB-AHCC audit tool) implementation, which involved interviewing 20 representatives from public health and community services who participated in the study.8
Barriers and facilitators of audit tool implementation
Barriers and facilitators of tool implementation were only described in one of the examined articles (the KB-AHCC audit tool, V.8). These barriers and/or facilitators were identified through participant evaluation of tool comprehensiveness, structure, communication; organisational responsibility for implementation; prioritising organisational cultural competence; and accountability. The study findings revealed more barriers than facilitators in relation to tool implementation. Some participants expressed a general positive view of tool structure and comprehensiveness as being a facilitator, it being valuable for identifying areas for action for healthcare workers and enabling involvement across organisations. However, the study also revealed that tool structure and comprehensiveness were also seen by some as a barrier, being considered too time-consuming and inflexible. Some participants expressed confusion about the difference between the KB-AHCC audit tool and other cultural competency tools/projects they had knowledge of, and this was regarded as a barrier for tool implementation. Additionally, the study revealed that tool implementation was often the responsibility of a small team or single staff member, which was thought to undermine opportunities for organisational engagement and causing issues when staff changes occurred. Another identified barrier was the challenge of prioritising cultural competence and there was a risk of it being deprioritised among other organisational responsibilities. Finally, the tool was not mandated as a practice instrument, therefore there seemed to be a lack of accountability for the implementation of the audit tool, identified as a significant barrier to implementation.
Alignment of audit tool characteristics with IAHA framework
The characteristics of 12 audit tools that were included in the 15 articles were mapped against IAHA’s Cultural Responsiveness in Action Framework to assess how well each tool reflects the 6 capabilities articulated in the framework. Audit tool mapping against the IAHA capabilities is shown in table 4.
Studies mapped against IAHA capabilities
Respect for the centrality of cultures
Respect for the centrality of cultures ‘identifies, respects and values cultures, both group and individual, as central to Aboriginal and Torres Strait Islander health and well-being’.5
This capability was demonstrated as a key characteristic in 11 out of 12 audit tools in the reviewed articles. The 11 tools described the value of healthcare practitioners/students having cultural and historical knowledge (eg, cultural awareness and respect, understanding impacts of racism and dominant cultures, respecting community protocols). Most tools reflected the importance of person-centred practice (ie, placing Aboriginal and Torres Strait Islander people at the centre of care) (n=8; 6, 8, 13, 14, 16, 22–24). Using a holistic and strengths-based approach to practice that emphasises the value of culturally specific skills and policies was also a key characteristic in the audit tools (n=8; 6, 8, 13, 14, 16, 22–24). More specifically, valuing the unique cultural lens that the Aboriginal and Torres Strait Islander workforce brings was a characteristic of two audit tools.6 19
Self-awareness
The self-awareness capability relates to the ‘continual development of self-knowledge, including understanding personal/organisational beliefs, assumptions, values, perceptions, attitudes and expectations, and how they impact relationships with Aboriginal and Torres Strait Islander peoples’.5
Self-awareness was reflected in eight studies (five audit tools; 14–16, 19–21, 23, 25). These five tools highlighted the importance of recognising and understanding one’s own cultural background, values and biases. The CICRT tool identified in Bennett and Morse21 and the GY tool in West et al22 23 and Biles et al24 also reflected the self-awareness capability through use of reflective practice on an individual level (eg, reflecting on how self-identity and biases impact relationships with Aboriginal and Torres Strait Islander people).
Proactivity
Proactivity is about ‘anticipating issues, initiating and embedding change that creates the best possible outcomes. It involves acting in advance of a possible situation, rather than reacting or adjusting’.5
Proactivity was identified in six audit tools.8 13 14 16 19 21–25 Two audit tools reflected the importance of healthcare professionals/students having the responsibility to challenge practices, and recognise and address personal biases, to provide culturally safe care.16 22–25 The other five audit tools highlighted the need for new and existing staff to undertake regular training, professional development and/or mentoring in cultural responsiveness and community engagement.8 13 14 19 21
Inclusive engagement
Inclusive engagement ensures that individuals and organisations ‘honour Aboriginal and Torres Strait Islander self-determination with opportunities to lead, participate and engage in meaningful and supportive ways’.5
This capability was demonstrated in nine audit tools.6 8 13–16 18 20 21 Relationship building and effective communication with Aboriginal and Torres Strait Islander people and communities was a characteristic of eight of these audit tools.6 8 13 14 16 18 20 21 Eight tools included implementation of self-determination processes (eg, having Aboriginal and Torres Strait Islander people actively participate and lead planning, monitoring and evaluation of services) as an important feature.6 8 13–16 18 20
Leadership
The capability of leadership is explained through ‘inspiring others, leading and influencing change in contributing to the renewal of the health and well-being of Aboriginal and Torres Strait Islander individuals, families and communities’.5
Leadership was a characteristic in only two studies.14 21 This capability was demonstrated through the importance of having individual and organisational responsibility to promote successes in working with Aboriginal and Torres Strait Islander people and communities and advocate for improvements to service delivery.
Responsibility and accountability
Individuals and organisations demonstrating responsibility and accountability ‘take responsibility for renewing Aboriginal and Torres Strait Islander health, monitors outcomes and progress and reports to Aboriginal and Torres Strait Islander peoples’.5
Five audit tools reviewed reflected this capability.6 13 14 16 21 All five tools met the responsibility and accountability capability by ensuring service outcome related data is collected, analysed and monitored to continuously improve service delivery.6 13 14 16 21 However, only one of these audit tools extended this data collection by providing opportunity for individual and/or organisational critical reflection based on the data collected6; another tool reinforced the importance of reporting findings back to communities.21
Discussion
This review aimed to develop an understanding of the characteristics that are included in existing audit tools for culturally safe and responsive healthcare, the barriers and facilitators for the effective implementation of existing audit tools and how they align with the IAHA capabilities. Overall, all articles discussed the importance of audit tools in providing a platform to develop and monitor culturally safe healthcare practice. There was agreement that such tools are useful and user-friendly in providing necessary capabilities with which to approach engagement and practice with Aboriginal and Torres Strait Islander people and their communities. An important aspect for implementation was having validated tools, where the tool reflects the capabilities or principles that it intends to. In theory, this was thought to be an advantage for health outcomes; however, despite all 15 articles discussing the challenges of evaluating tools and their relationship to perceived improvements in health outcomes and cultural safety experiences, only 1 article reporting on the evaluation of a tool8 was found when reviewing the literature. Exploring the barriers and facilitators of tool implementation was a key question for this scoping review; however, limited insight can be gained from just one study and further research on tool implementation is required.
Some aspects of the IAHA framework were clearly reflected in the audit tools reviewed (ie, respect for the centrality of cultures and inclusive engagement); however, others were not as strongly reflected in the tools (ie, self-awareness, proactivity, leadership, and responsibility and accountability).
Respect for the centrality of cultures and inclusive engagement are essential for delivering culturally safe and responsive healthcare to Aboriginal and Torres Strait Islander people and communities.5 Training on cultural and community knowledge, using a person-centred approach to practice and working with Aboriginal and Torres Strait Islander people and communities has led to more respectful relationships, client-led practice, improved perceptions of preparedness and confidence, and enhanced knowledge, skills and attitudes for healthcare professionals.26–32 When healthcare professionals are provided with such training, there are also improvements to client’s reported quality of life, relationship building with Aboriginal and Torres Strait Islander communities and improved client-practitioner communication.6 8 33 34 All audit tools, except one, in this review demonstrated the capability of respect for the centrality of cultures, and nine audit tools reflected inclusive engagement. These capabilities have simpler practical strategies outlined and, thus, may be more ‘easily’ integrated into audit tools and organisational policies and procedures. Incorporation of these capabilities, and cultural safety and responsiveness more broadly, may also reflect a major proportion of the examined tools being developed and implemented in a nursing and midwifery context. Alignment exists between these capabilities and the philosophy of midwifery practice in supporting safe birthing through person-centred practice, compared with most other allied health disciplines that adopt a predominantly biomedical philosophy to practice. For these reasons, respect for the centrality of cultures and inclusive engagement are popular drivers of audit tools examining culturally safe and responsive practice in Australia.
Inclusive engagement, however, was found in less audit tools than respect for the centrality of cultures. This is because of the required sustained effort needed for individuals and organisations to maintain partnerships or connections with Aboriginal and Torres Strait Islander people and communities.8 Building rapport with community takes time.31 However, excluding this capability does not allow for the ongoing and sustainable change to healthcare systems required for culturally safe practice.5 Integrating all capabilities, as interconnected capabilities, improves the cultural safety and responsiveness of a healthcare practitioner or organisation and, in turn, supports Aboriginal and Torres Strait Islander health.5 Incorporating all capabilities into an audit tool enables organisations to move away from the notion of cultural competence and more towards an ongoing culturally responsive approach.
The reviewed tools were limited in demonstrating more inward facing capabilities needed for culturally safe and responsive healthcare delivery—self-awareness, leadership, proactivity, and responsibility and accountability. This reflects the varying terminology used in these tools as well as the broader conversation and healthcare agenda in its shift in focus from cultural awareness to cultural safety and responsiveness approaches to practice. Tools demonstrating these capabilities appeared to be at the cultural safety end of the spectrum, whereas those that did not were focused on cultural awareness. All four of these capabilities are essential for culturally safe and responsive healthcare practice; however, for individuals and organisations, engaging in such capabilities remains challenging. Historically, audit tools have been dominated by Western perspectives and othering of Aboriginal and Torres Strait Islander people and knowledges. This results in a more prescriptive process of ‘ticking a box’, as opposed to engaging in a culturally responsive ongoing process of deep, self-reflection.35 36 This is where the capability of self-awareness is critical. Understanding and reflecting on one’s own cultural background and biases and those inherent within our systems and practices has been shown to improve healthcare professionals’ confidence, skills and engagement with clients.37 38 Leadership, proactivity, and responsibility and accountability have also all led to reported improvements in relationship building with Aboriginal and Torres Strait Islander people, service volume (eg, increase in Aboriginal and Torres Strait Islander patients seen), the identification of gaps for improvement and workforce development.6 8 34 Advocating for change in the workplace and undertaking regular training and professional development in cultural responsiveness and community engagement is particularly important for audit tool inclusion, as this approach fosters key qualities needed for healthcare workers in Australia to ensure cultural safety and responsiveness, eliminating a one-size-fits-all approach to practice. In delivering culturally safe approaches, sustained responsibility and accountability to Aboriginal and Torres Strait Islander people and communities by ensuring opportunity for service delivery input and feedback is required.6 24 Despite this, audit tools focused on all six capabilities, to our knowledge, remain undeveloped.
Limitations
This review was limited by our inclusion criteria of articles only relevant for Aboriginal and Torres Strait Islander people in Australia. Examining audit tools from countries who share similar colonial experiences, such as New Zealand, the USA and Canada, may provide further useful information for tool implementation and evaluation. Our findings may be useful for researchers in these countries wanting to undertake similar research. Alongside exploring international knowledges, examining tools related to non-health sectors, such as education, could provide further insight. The inconsistency in terminology (eg, ‘cultural competency’, ‘cultural capability’, ‘cultural responsiveness’) and definitions used in articles also made comparison difficult. Despite a large database search, tools predominantly related to cultural competency and cultural safety, as opposed to cultural responsiveness. Applying a cultural responsiveness lens to assess cultural safety, when mapping tools against the IAHA framework, was still deemed appropriate because of cultural responsiveness’ origins in cultural safety and its focus on organisation and practitioner experiences. The tools found through our search related to these experiences as opposed to client experiences. Although we attempted to include all relevant articles through systematic database searches, some articles may have been missed.
Conclusion
Action-oriented tools—that reflect all the capabilities of cultural responsiveness, as identified by IAHA—need to be implemented effectively to transform standard practice and ensure organisational accountability. Progressing broader health system change may require tools to align with more inward facing capabilities, as identified by the research team. These capabilities include self-awareness, proactivity, leadership, and responsibility and accountability. This review highlights the clear gaps in research that allows understanding of tool implementation and how tools align with IAHA’s capabilities. These capabilities need to be considered for audit tools at an individual and organisational level, and incorporated into policy to continuously improve service delivery, reflecting the ongoing nature of cultural responsiveness. Further evaluative research on such tools is needed to gain a deeper understanding of the barriers and facilitators for implementation.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
References
Footnotes
Handling editor Seye Abimbola
Contributors All authors contributed to the writing and editing of this review and share responsibility for the final version. JM is the guarantor of this work.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.