Insights (Essays)

Insights (Essays) December 2018

The Self-Reflexive Path to Cultural Safety

Crystal Milligan


I may simply be lucky or naïve or only mix in idealistic crowds, but I have never met a healthcare professional who did not want to make a difference in other people’s lives. Whether we are clinicians, administrators, researchers or other professionals working in healthcare, we do what we do in order to help others. We are highly trained, intrinsically motivated and work hard. 

So how is it that a growing body of evidence points to our own healthcare organizations as key contributors to poor health among Indigenous (First Nations, Inuit and Métis) peoples living in Canada 1–4.

The problem

Throughout Canadian history, an inequitable structural framework has created and perpetuated systemic discrimination toward Indigenous peoples. The cornerstone of this framework is the Indian Act. Largely unchanged since it was first passed in 1876, the Indian Act successfully severed Indigenous peoples’ ties with ancestral lands and enforced dependency on the federal government for food, housing and healthcare—basic needs hitherto sustained by the land and pre-existing social structures. Though it did not succeed in assimilating Indigenous peoples, the Act continues to have a profound effect on their autonomy, cultural continuity and connection with the things that had previously supported their health. 

This history is not just in the past. We continue to live within a framework that favours the voices, experiences and ways of knowing of White Settler Canadians such as myself. This same framework consistently mistrusts or denies the voices, experiences and ways of knowing of Indigenous peoples. Of the many healthcare stories shared with me by my Indigenous friends, colleagues and community partners, a large majority reveal a persisting attitude that their concerns cannot be taken seriously. I am not sure whether I would have their strength and resilience in the face of such barriers.

As healthcare leaders, we have power and privilege to correct this but good intentions do not always translate into good results.

Enter self-reflexivity

In my experience, the first step is to look within. It has only been since I began to nurture a critical, self-reflexive approach to understanding colonization and my own privilege that I began to move away from unwittingly upholding inequitable structures, and toward dismantling them.

Cultural awareness, sensitivity, and competency are not enough. From a young age, I have been able to see similarities and differences between cultural groups (cultural awareness). I like to think as well that I accept other groups without judgment (cultural sensitivity) and can work across cultures (cultural competency) 5. However, critical self-reflexivity is what helps me avoid promoting stereotypes and the simplistic idea that I can easily learn a set of skills to navigate other cultures. 

In 1990, Maori nursing scholar, Irihapeti Ramsden, introduced the concept of cultural safety, which includes a self-reflexive practice to critically examine our hidden assumptions, power and privilege 6. In culturally safe healthcare or research, the patient or knowledge holder feels respected and safe to be who they are. Instead of a magnifying glass to look at the Other, we hold up a mirror to scrutinize our own roles in an inequitable structural framework. If done in a supportive environment, this unsettling process can spark transformative learning and new capacity to create cultural safety. This journey can be an enlightening one, particularly when taken in relationship. 


Indeed, our most essential resources for enabling self-reflexivity are the relationships we have with individuals and groups who hold ways of knowing that are different from our own. Rather than go it alone, the self-reflexive healthcare leader nurtures relationships with Indigenous Elders and knowledge holders, communities and patients. Respectful and reciprocal relationships reveal ways in which the healthcare system might adapt to meet Indigenous peoples’ needs.

We may also access short courses, such as the San’yas Indigenous Cultural Safety Training Program 7 or Cancer Care Ontario’s modules on Aboriginal Relationship and Cultural Competency 8, that offer foundational knowledge to support and deepen our self-reflexivity. 

Moving forward 

I am probably neither lucky nor naïve, though I will accept a label of idealistic. I have faith in the inherent goodness of people working in healthcare, and believe change is possible.  

As healthcare leaders, our responsibility to implement the United Nations Declaration on the Rights of Indigenous Peoples 9, together with the Truth and Reconciliation Commission’s Calls to Action 2, is intimately intertwined with our responsibility to learn not solely about the Other, but from the differences in our experiences. 

We can start by recognizing where systemic problems lie, and our roles in either perpetuating or dismantling them. Self-reflexivity is thus crucial—because until we ask the right questions of ourselves, we will continue struggling to find the right solutions.



1. Royal Commission on Aboriginal Peoples. People to People, Nation to Nation: Highlights from the Report of the Royal Commission on Aboriginal Peoples. Ottawa, ON: Minister of Supply and Services; 1996. 

2. Truth and Reconciliation Commission of Canada. Calls to Action. Winnipeg, MB: Truth and Reconciliation Commission of Canada; 2015. 

3. Allan B, Smylie J. First Peoples, Second Class Treatment: The role of racism in the health and well-being of Indigenous peoples in Canada [Internet]. Toronto, ON: Wellesley Institute; 2015. Available from:

4. Reading C. Structural Determinants of Aboriginal Peoples’ Health. In: Determinants of Indigenous Peoples’ Health in Canada: Beyond the Social. Toronto, ON: Canadian Scholars’ Press; 2015. p. 3–15. 

5. Ward C, Branch C, Fridkin A. What is Indigenous Cultural Safety–and Why Should I Care About It? Visions [Internet]. 2016;11(4). Available from: 

6. Ramsden I. Cultural safety. N Z Nurs J Kai Tiaki. 1990;83(11):18–9. 

7. San’yas Indigenous Cultural Safety Training [Internet]. Provincial Health Services Authority in BC. n.d. Available from:

8. Aboriginal Relationship and Cultural Competency Courses [Internet]. Cancer Care Ontario. 2016. Available from:

9. United Nations Declaration on the Rights of Indigenous Peoples: Resolution Adopted by General Assembly [Internet]. UN General Assembly; 2007 Oct. Available from:


About the Author(s)

Crystal Milligan is a global health manager and researcher from Yellowknife, Northwest Territories, home to the Yellowknives Dene First Nation. She is a PhD student at the Institute of Health Policy, Management and Evaluation within the Dalla Lana School of Public Health at University of Toronto. Her PhD research will help to inform the incorporation of Indigenous values and health beliefs into Canadian healthcare systems.


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