Q1: What is CSH and how does it apply to the practice of dietetics?
Cultural safety is an outcome based on respectful engagement that recognizes and strives to address power imbalances inherent to health care relationships. It results in an environment free of racism and discrimination, where people feel safe and supported to access, receive, and make informed decisions about their health care.
Cultural humility involves educating health professionals on the history of the treatment of Indigenous peoples throughout Canadian history and facilitate self-reflection in understanding personal and systemic biases that may prevent Indigenous peoples from accessing health care. It aims to develop relationships based on reciprocal trust and listening, while acknowledging oneself as a learner when it comes to understanding another’s experience.
*Adapted from Cultural Safety and Humility (fnha.ca)
The principles of cultural safety and humility (CSH) align well with dietitians’ responsibility to practice ethically, safely, and competently.
Q2: Do you have any information on how I could include CSH in my CCP report?
Under the Health Professions Act, Dietitians are responsible to maintain and enhance their standards of practice through lifelong learning and reporting in the CDBC’s Continuing Competence Program (CCP). The CCP is founded on the CDBC Standards of Practice and include seventeen standards divided into four pillars of practice. Out of the seventeen standards, the following standards cover aspects of practice that are relevant to CSH:
- Professional and Ethical Practice (standard 4, ethical practice and standard 6, informed consent).
- Communication and Collaboration (standard 9, clear, respectful and culturally sensitive communication).
- Client-centered Services (standard 12, quality client-centered service that reflects client context, needs, values and goals, standard 13, evidence-informed service inclusive of client perspective and circumstances, and standard 14, use of critical thinking to incorporate elements of cultural competence and patient advocacy in care planning).
- Leadership, Organization & Service Delivery (standard 16, risk management strategies and continuous quality improvement).
In 2020-21, standard 9.8 “A dietitian speaks in a clear, concise, and respectful manner… demonstrate[s] cultural competence” was selected the most by registrants to report on continuing education. This truly demonstrates current need and interest in the profession to learn more about this important topic.
Q3: Is Standard 9.8 the only standard I can select to report CSH learning?
As mentioned in Q2, there are at least 7 different standards that are relevant to applying the principles of CSH into different areas of dietetic practice. You are encouraged to critically review the Standards of Practice, Indicators, and Outcomes to determine which Standard/Indicator combination best describes the area of CSH you are looking to develop and integrate to your practice. It is the same approach you would take with any learning goal.
Q4: I am finding making a true SMART goal for cultural competence very difficult, since it is a soft skill and difficult to measure. Is it ok to describe a learning outcome as a feeling (an increase in comfort, or confidence)?
You are encouraged to develop SMART goals in learning reports whenever feasible. The CDBC recognizes difficulty in developing truly measurable goals in Standards that promote soft skill development, such as cultural competency.
“Measurable” can defined as being able to quantify the desired outcome to allow tracking of your progress in the context of goal setting.
Quantifiability of a goal means that it can be explicitly measured, such as % reduction in a waste audit, an improvement in blood glucose among clients, score on an exam, etc. These can easily be used to demonstrate that a goal has been achieved.
However, in the case of a cultural competence goal, outcome is often measured qualitatively, an outcome that is descriptive and conceptual. Examples of qualitative measures include communicating more effectively, learning to better adapt to change, working collaboratively with a team, etc. With intangible learning outcomes, you may consider tracking your goal internally. Some questions to ask yourself include:
- Do I feel more comfortable about discussing the topic covered in my learning goal?
- Have I gained a better understanding?
- What has completing the learning report help me to achieve?
In both the qualitative and quantitative measures of goal achievement, the learning outcome description of the Professional Development Report (PDR) is very important, especially so in a qualitative goal. Here, you can use the space to truly reflect on how your intangible learning (goal achievement and thus meeting the Standard/Indicator combination) has affected your practice of dietetics in a positive way. These reflections are a powerful way in which to express advancement in professional practice and competency1.
1 Koshy et al (2017). International Journal of Surgery. Oncology. Reflective practice in health care and how to reflect effectively. Accessed June 29, 2021.
Q5: Can I get help in formulating a SMART goal with a qualitative measured outcome?
You may find the following framework1-4 helpful when developing goals for soft skills:
Questions to consider
What part of the CCP is this?
1. Provide context
· What does improvement in cultural competence mean to me?
· When and how do I need to practice cultural safety in my professional setting?
· Where am I in my cultural competence journey?
Self Assessment and Learning Goal
· Consider which Standard/Indicator combination best fits your learning needs.
· Start drafting a SMART learning goal in that section of the PDR.
2. Determine desired outcome
· What aspect of cultural competence am I looking to improve?
· What am I looking to achieve?
· Where can I seek out education opportunities?
· Why is this important?
Portfolio and Learning Activities
· This may be reinforced and reassessed over time as a dietitian undertakes opportunities for learning in the desired area.
· Compile learning activities into a Professional Portfolio and seek additional learning in areas of interest/necessity.
· Record learning activities in that section of the PDR.
3. Identify outcome measures
· How will I know I have achieved my goal?
· Are these outcomes (quantitative) measurable, or are they qualitative in measure (a change in perception/paradigm, a feeling of confidence/comfort in a new area, or a sense that your role has been positively impactful)?
· This is where a dietitian reflects on the qualitative outcome of this goal.
· What was achieved? Is there more learning that needs to be done?
· Finalize the SMART learning goal in that section of the PDR.
4. Evaluate the outcome measures
· How will I evaluate my success measures?
· Did I learn more about the application of the Standard/Indicator in my practice?
· This is the last reflective stage of the PDR where a dietitian identifies how this learning and goal achievement has improved their practice of dietetics.
· Is there an additional goal for the next CCP cycle that could be developed from this learning?
For sample learning plans on cultural competence-based goals, please refer to Question 6.
1CDBC. SMART goal video.
2College of Dietitians of Ontario. SMART goal webinar. https://www.collegeofdietitians.org/resources/quality-assurance/self-directed-learning-tool/sdltool-webinar-smart-goals.aspx, accessed June 30, 2021.
3Eileen Azzara (2016). SMART goal examples for developing leadership competencies. SMART Goal Examples for Developing Leadership Competencies (linkedin.com), accessed June 21, 2021.
4McGill University (n.d.). Smart goals and intrinsic motivation. https://www.mcgill.ca/engineering/files/engineering/smart_goals_and_intrinsic_motivation.pdf; accessed on May 14, 2021.
Q6: Do you have examples of SMART learning goals and learning outcomes specific to cultural competence?
We would like to share three sample learning reports related to cultural humility and competence for Indigenous populations. The purpose of the sample learning reports is to clarify how the SMART learning goal model may be adapted for qualitative outcomes for soft skill development and provide inspiration to registrants. You may choose how you would like to develop your learning reports as long as that they comply with the CCP guidelines. To learn about tips on writing SMART goals for soft skills, please refer to Q5.
The learning activities section of the learning reports below has not been included. These opportunities can be specific to geographical region, time of year, and community/workplace engagement and can become easily outdated. For more information and to access examples of resources for your learning needs, please see Q7 below.
Note that the letters S-M-A-R-T have been included so sections of the learning report can be identified.
Standard 12: A dietitian provides quality professional services that reflect the unique needs, goals, values, and circumstances of the client.
Indicator 1: Provide quality professional services respecting the client’s ancestry, nationality, ethnic background, religion, age, gender, social and marital status, sexual orientation, political beliefs or physical or mental ability.
Learning Goal: My aim is to improve my cultural competence (R) within this 1-year CCP cycle (T) to ensure inclusion of Indigenous members of my community (A) such that they can receive care that is consistently culturally safe. I would like to feel more confident (M) about plans of care that (1) reflect unique perspectives of this population and (2) address systemic barriers which have often caused poor outcomes in this population (S).
- Not included, reasoning above.
Learning Outcome: My learning this CCP cycle has been tied to an acknowledgement and understanding of the systemic racism that pervades our healthcare system. I was able to work within my interdisciplinary team to plan for consistently culturally safe care and to revise our language (both written and spoken) to avoid colonialist wording and phrasing, providing a more inclusive and welcoming experience for all.
Standard 4: A dietitian acts ethically in their professional interactions and while providing professional services.
Indicator 3: Demonstrate inclusion, honesty, and fairness.
Learning Goal: This year (T), I would like to learn how to provide meaningful land acknowledgements (S) at the outset of all meetings and webinars/seminars (A) that truly reflect my desire to be an ally and meaningfully contribute to reconciliation by demonstrating gratitude and humility (M) while avoiding the perpetuation of colonization’s damaging effects (R).
- Not included, reasoning above.
Learning Outcome: I feel I have gained knowledge and understanding that translate well into practical tips on how to approach a land acknowledgement, such that it has maximum impact and sincerity. I gained an appreciation for the need to take time to develop such an acknowledgment, by providing thoughtful and reflective practices to the process.
Standard 9: Clear, respectful, and culturally sensitive communication.
Indicator 3: Demonstrate cultural competence.
Learning Goal: By mid-way through this CCP cycle (T), I would like to read about sources of power imbalances that exist in healthcare between healthcare practitioners and Indigenous patients in BC (A), and their impact on safe care delivery (S, R) with the aim of being able to name and discuss (M) sources of power imbalances and impact on care of Indigenous patients with my team.
- Not included, reasoning above.
Learning Outcome: Learning about the power imbalances in healthcare and how Indigenous populations are affected allowed me to gain a better understanding of the challenges Indigenous Peoples face. This learning helped me strengthen my understanding of the importance of cultural safety and what it entails in healthcare. Providing a culturally safe environment in a healthcare setting involves integrating cultural humility and competency into practice, and having cultural awareness is not enough. I realize that I am only in the beginning stages of gaining cultural competence, and I am inspired to further improve my cultural competence as an individual and a team member, keeping the “learner” perspective in mind.
Q7: I am interested in learning more about CSH and Indigenous-specific racism. Can you recommend some resources to start with?
The CDBC acknowledges that the following resources are not exhaustive and are provided as a starting point. Registrants may find that this information can be complemented by additional resources on trauma-informed practice and decolonizing the dietetics profession.
- BC Patient Safety & Quality Council. Cultural Safety & Humility
- Culturally Connected. References
- DC Webinar Truth, reconciliation, and food
- First Nations Health Authority
- Indian Residential School History & Dialogue Centre
- Indian Residential School Survivors Society
- In Plain Sight Addressing Indigenous-specific Racism and Discrimination in B.C. Health Care
- Métis Nation British Columbia. 2021. Kaa-wiichitoyaahk: We Take Care of Each Other. Métis Perspectives on Cultural Wellness
- Ministry of Indigenous Relations and Reconciliation – Province of British Columbia (gov.bc.ca)
- National Indigenous Cultural Safety Learning Series. ICS Collaborative – PHSA
- NCCIH – National Collaborating Centre for Indigenous Health. Resources relevant to the health of Canada’s Indigenous peoples
- San’yas Indigenous Cultural Safety Training
- The dark history of Canada’s Food Guide: How experiments on Indigenous children shaped nutrition policy
- The Residential School System
- Truth and Reconciliation Commission of Canada. Residential Schools of Canada
The CDBC would like to acknowledge Cindy Huang, UBC Dietetics graduate and new CDBC registrant, for her thoughtful and well-researched contributions to this month’s Q&A.