Furthering Cultural Safety in Kidney Care Within Indigenous Communities: A Systematic and Narrative Review.

RATIONALE &
OBJECTIVE: Cultural Safety is being prioritized within health care around the world. As a concept, Cultural Safety centers upon power relations between health providers and indigenous recipients of care, ensuring that all people feel safe and respected in the health care system. In this article, we explored the breadth of the literature regarding Cultural Safety within the context of indigenous kidney health care. STUDY DESIGN & POPULATIONS: As a systematic narrative review, this work engaged widely across a diverse range of the available literature to broaden understanding of Cultural Safety within indigenous kidney health care and indigenous populations from Australia, New Zealand, Canada, and the United States. SEARCH STRATEGY & ANALYTICAL APPROACH: Guided by the research question focused on how Cultural Safety occurs within care for indigenous people with kidney disease, an initial database search by the university librarian resulted in retrieval of 2,232 articles, of which 96 potential articles were screened by the research team.
RESULTS: 15 articles relevant to the research question were identified and study findings were assembled within 3 broad clusters: relationality, engagement, and health care self-determination; systemic issues, barriers, and access; and addressing legacies of colonialism for health care providers. LIMITATIONS: The review summarizes mainly qualitative articles given the paucity of articles found specific to Cultural Safety within indigenous contexts.
CONCLUSIONS: Of particular interest to health care providers are the collation of solutions by cluster and the findings of this review that contribute to further understanding of the concept of Cultural Safety in health care for indigenous people with kidney disease. Also, findings address the importance of community-driven kidney care in which language, ways of knowing and being, and traditional ways of healing are prioritized.

This study identified various scientific papers that discussed Cultural Safety for indigenous people with kidney disease. In this review, a team of researchers within Canada explored published articles from Australia, New Zealand, Canada, and the United States. The researchers wanted to discover how Cultural Safety happens in kidney health care. There is little research published on Cultural Safety in kidney care and we were able to locate 15 articles on this topic. We organized the articles that had similarities into 3 groups and then highlighted solutions aligning with community culturally based care. The results of our study should help improve the understanding of Cultural Safety for indigenous people with kidney disease and prioritize traditional ways of healing within community-driven care.

Editorial, p 881

During the 2020 pandemic year, the world witnessed an escalation of protests and media attention concerning racial incidents within health care. There has also been an increasing emphasis on the need for Cultural Safety∗ within mainstream health care in Canada.2, 3, 4 We begin here by describing the concept of Cultural Safety, its associated meanings, and its relevance to indigenous kidney health care and chronic kidney disease.

Many are familiar with the well-publicized case of Brian Sinclair, who, in 2008, died in a Winnipeg, Manitoba, emergency department while waiting 34 hours for care for a serious bladder infection., In their 2015 report, First peoples, second class treatment: The role of racism in the health and well-being of Indigenous peoples in Canada, Drs Billie Allan and Janet Smylie emphasize the embedded disparities within colonial policies that continue to severely impact on the provision of equitable health resources. Papps and Ramsden (1996) explain that Cultural Safety “raises the issue of racism” and race relations that may trigger unease for those in denial and for those who acknowledge it. In this regard, learning of Cultural Safety needs to be prioritized. The concept of Cultural Safety “pays explicit attention to power relations between service user and service provider”7(p3) and therefore differs from cultural competence and sensitivity that focus on a person’s culture. Cultural Safety cannot happen without cultural humility, which involves self-reflection and acknowledging one’s own lens.

From Reclaiming Power and Place: The Final Report of the National Inquiry Into Missing and Murdered Indigenous Women and Girls, the meaning of Cultural Safety extends “...beyond the idea of cultural 'appropriateness' and demands the incorporation of services and processes that empower Indigenous Peoples.”8(p3) Cultural Safety demands the “inclusion of Indigenous languages, laws and protocols, determination, spirituality, and religion.”8(p173) In addition, the “concept of client-centred care and ‘getting to know the individual’ may not foster Cultural Safety for indigenous and racialized clients who understand relationships, knowledge, and space as interconnected manifestations of family and kinship-based societies.”9(p10) Relationships within community and to the land or relational ways of being and knowing are prioritized over individualism.,,7, 8, 9

Our team, including First Nation members, nursing scholars, and a nephrologist, is focused on improving indigenous† kidney health throughout Canada. As an eclectic research team, we attempted to identify what already exists in terms of Cultural Safety for indigenous populations with kidney disease in Canada and internationally from a variety of sources. Our research specifically sought to understand and address how Cultural Safety occurs within contexts of health care for indigenous people with kidney disease.

Methods

The narrative review systematically incorporates a broad spectrum of literature and facilitates an evidence synthesis and interpretation that is both holistic and reflective of the unique insights and experiences of reviewers., Narrative reviews “provide interpretation and critique; their key contribution is deepening understanding."12(p2) In addition, this type of review fosters clarification and insight as relevant to philosophy and history. Cultural Safety is a concept that links to the historical legacy of colonialism and indigenous epistemologies and is favorable to a narrative review. This work comprehensively synthesizes peer-reviewed qualitative, quantitative, and mixed research studies and reviews toward offering rich and diverse perspectives.

Based on our research question, how Cultural Safety occurs within contexts of care for indigenous people with kidney disease, the following databases were searched by a librarian with experience in systematic reviews (ARW): Cumulative Index to Nursing and Allied Health Literature (CINAHL) on the Ebsco platform, Medline, EMBASE, and Cochrane CENTRAL on the Ovid platform, ProQuest Nursing and Allied Health Database, and Web of Science Core Collection (including Science Citation Index: 1900-present; Social Sciences Citation Index: 1956-present; and Arts and Humanities:1975-present).

The search strategy included a search filter for indigenous literature developed by the University of Alberta, as well as search strategy for Aboriginal and Torres Strait Islander literature developed by the Lowitja Institute. Key terms were also searched in Google Scholar. A full search strategy for the Medline database is available at http://hdl.handle.net/1974/28582. We identified 2,232 records through the database searches for screening after duplicates were removed.

Inclusion criteria encompassed Cultural Safety concepts within the context of indigenous kidney care, including race relations, the legacy of colonialism, self-determination and land, indigenous ways of knowing and being, language, and relationality.,, Articles between 2002 and 2020 were chosen. The date of 2002 correlates with the time that Irihapeti Merenia Ramsden published her thesis titled Cultural Safety and Nursing Education in Aotearoa and Te Waipounamu in which the term then began to be used more widely in the literature. Excluded records lacked association with Cultural Safety within indigenous kidney contexts and connection to chronic kidney disease, dialysis, and/or transplantation. This resulted in 96 potential articles for full-text screening by our research team. Both indigenous and nonindigenous members of the research team engaged in feedback on the chosen articles that were distributed through secure online collaborative sites and discussed during research team meetings.

Results

Fifteen studies met the criteria of Cultural Safety within indigenous kidney care and were included in this review (Fig 1). We found articles both from Canada and internationally that encompassed Cultural Safety concepts within the context of indigenous kidney care (Table 117, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30). Most studies were published between 2014 and 2020. There were 10 qualitative studies, 2 quantitative studies, and 3 reviews, 1 scoping and 2 systematic. Although there are shared commonalities across all the articles, we arranged the research findings into 3 clusters aligned with Cultural Safety concepts. Clusters were determined through reading and re-reading articles and discussing their relevance to the research question within online team meetings and shared emails that involved both indigenous and nonindigenous research team members. The clusters include relationality, engagement and health care self-determination; systemic issues, barriers, and access; and addressing legacies of colonialism for health care providers. Solutions per cluster are represented in Box 1.17, 18, 19, 20, 21,24, 25, 26, 27, 28, 29, 30, 31 There were 6 articles clustered under the heading of relationality, engagement, and health care self-determination: 4 articles in relation to systemic issues, barriers, and access; and 5 articles related to addressing legacies of colonialism for health care providers.

Figure 1

Flow chart. Based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow chart.

Table 1

Publications Relevant to Cultural Safety Concepts Within the Context of Indigenous Kidney Care

Reference, Country	Research Question(s) or Purpose/Objectives	Research Design/Methods	Participants	Results and Connection to Cultural Safety
Richels et al17 (2020), Canada	Identify existing barriers to home peritoneal dialysis; provide insight for a culturally meaningful framework for future programs in First Nations communities in Saskatchewan	Qualitative research - sharing circles, individual interviews	67 participants in sharing circles	Themes included: logistics, education and information, training and support, community support, and culture and leadership; notes underuse of home-based peritoneal dialysis
Jansen et al19 (2020), Canada	Identify culturally appropriate and co-developed indigenous educational tools to support CKD learning and end-stage kidney treatment decision making	Scoping review	1 article; CKD tool co-developed by researchers	Engaging with indigenous communities requires in-depth understanding; the co-development of indigenous CKD educational tools is lacking
Hughes et al18 (2019), Australia	Describe health care experiences in relation to a government’s kidney health care	Qualitative interviews	26 adults	Acknowledges land and self-determination concepts; identifies complaint of lack of respect and empathy from health care providers; addresses needs to further health care quality
Walker et al21 (2019), New Zealand	Identify systemic barriers and understanding of cultural values that influence kidney transplantation	A systematic review of qualitative studies	225 indigenous participants in Australia, New Zealand, Canada, and the United States	Related to indigenous ways of knowing and being; identified barriers include distrust of health care systems, lack of knowledge of kidney transplantation processes, and discrimination; among indigenous participants, access to kidney transplantation was strongly desired
Conway et al23 (2018), Australia	Examine impact of mobile dialysis on health and well-being; facilitators and barriers	Semi-structured interviews	15 indigenous dialysis patients and 10 nurses	Country reference similar to a family bond, tradition, links with ownership and spirituality
Nelson et al20 (2018), United States	Examine efficacy of a home-based kidney care program	Clinical trail	98 rural adult Zuni Indians	A home-based intervention improved activation in own health and health care and may reduce CKD risk factors for disadvantaged rural area; interventions through community members who are trained furthered the educational process and helped engage patients in own care
Rix et al28 (2016), Australia	Aim to inform service improvement for Aboriginal kidney patients	Qualitative research; community-based research	18 Aboriginal hemodialysis patients and 29 kidney health professionals	Related to indigenous ways of being and knowing; land/self-determination colonialism; relationality; Cultural Safety requires listening to what people are saying
Reilly et al24 (2016), Australia, New Zealand, Canada	Examine benefits, cost-effectiveness, and suitability of CKD management programs for indigenous people, in addition to enablers and barriers	Systematic review of mixed evidence	10 studies were included	Describes the challenge of recruiting and retaining staff in remote communities, need for indigenous decision making, respect, ownership and health care workers
Kelly et al29 (2016), Australia	Develop a more responsive education program	Participatory action research	Kidney focus group of kidney and health care professionals	Related to knowledge of history/colonialism; humility and safety to be reflected through case studies; emphasis on indigenous Culturally Safe care
Walker et al22 (2012), New Zealand	Describe and discuss what predialysis nurses perceive to be key influences on effective predialysis nursing care	A descriptive exploratory approach	11 interviews with 11 nurses	Important to provide culturally appropriate and effective care; lack of culturally diverse educational resources identified as barrier to providing effective care; the Western approach of focusing on individuals is not always effective in this population
Rix et al27 (2014), Australia	Inform the provision of health care services as depicted by the indigenous people themselves	Qualitative stories	5 indigenous participants	Exemplifies Cultural Safety, uses storying, reflection on colonial historical past, unequal power relationships and indigenous ways of being and knowing within a kidney context
Shah et al25 (2014), United States	Identify barriers to health care in the Zuni Pueblo	14 one-hour focus group sessions	112 people	Recommends implementation of culturally community-based health promotion programs and preventive screening to improve access and reduce disparities
Walton30 (2011), United States	Describe differences regarding cultural knowledge and awareness in students before and after receiving education re indigenous experiences with hemodialysis therapy by a nephrology nurse; examine how students apply culturally relevant care when given a case scenario with CKD	Quantitative -pre- and post-tests based on 1-h presentation and qualitative-reflective paper	N = 95 nursing students	Indigenous ways of knowing and being are discussed; “Storytelling, networking, and involvement of Native American leaders, and the creation of new models that integrate cultural traditions in care may be keys to bridging the cultural gaps that exist”(p27)
Sicotte26 (2011), Canada	Compares health and care use of patients receiving tele-hemodialysis services	Pre-post design	N = 19	Telemedicine reduces the burden associated with access for hemodialysis
Walton30 (2011), United States	Explore what spirituality means to individuals receiving hemodialysis. and spirituality’s influence on their lives	Grounded theory	N = 21; 12 women and 9 men	Focus on spirituality, traditional approaches, consideration and recommendations for developing and transitioning into hemodialysis; also explores ways to decrease depression, reconcile past issues and further relationships

Abbreviation: CKD, chronic kidney disease.

Relationality, engagement and health care self-determination

Incorporation of translators, traditional approaches, Elders, peer support attention to funding and advocacy

Individualized education

Support for caregivers

Learning from and listening to Elders,,

Sharing stories that voice ways of knowing and being inclusive of indigenous art 17, 18, 19

Cultural Safety audits and continuity of service

Home-based care using local culturally consistent and community-based resources and personnel17, 18, 19, 20

Build trust through traditional ways to foster kidney organ donation and transplantation

Culturally appropriate social workers and cultural support personnel; promotion of indigenous kidney nursing

Indigenous engagement within health care education and administrative and organizational systems sectors

Systemic issues, barriers, and access

Recognition of significance of land and cultural attachments to place of origin

Dialysis service and kidney care in home remote communities

Increase indigenous health workers and capacity for involvement in decision making

Supporting community ownership furthers engagement in health prevention

Reliable transportation to medical facilities and pharmacies

Tele-hemodialysis reduced the burden associated with travel and the requirement for on-site health care providers that historically have had a high turnover rate

Addressing legacies of colonialism for health care providers

Self-reflective journey through journaling as a way to address harmful assumptions and sterotyping

Intensive listening conveys respect for both cultural or traditional worldviews

Having indigenous health workers within dialysis units

Paid Elders inclusive of family/community for cultural training of nonindigenous health workers

Include case studies relating to patient journeys in health care education

Need for ongoing indigenous involvement in reviewing the overall course and framework

Respect for smudging supporting use of meaningful symbols in prayer in dialysis care

Approaching with an open mind; establishing trust and a sacred space; assessing belief systems; ongoing education for the patient

Relationality, Engagement, and Health Care Self-determination

The publication by Richels et al addresses barriers to home peritoneal dialysis through a qualitative study involving sharing circles and interviews with First Nation communities from Saskatchewan. With regard to Cultural Safety, participants spoke about mistrust arising from colonization and systemic racism that ignored traditional healing, as well as differing treatment based on race. Solutions brought forward by the participants included incorporation of translators, traditional approaches, Elders, peer support, and attention to funding and advocacy. The need for individualized education and support for caregivers was further highlighted.

Similarly, a qualitative study by Hughes et al and a scoping review from Jansen et al emphasized community relational strengths and included supporting, assisting each other, and learning from and listening to Elders. These studies and another study by Nelson et al also identified a need for resources beyond written format that are inclusive of local language, traditional protocols, and ceremonies developed by communities themselves.18, 19, 20 For example, audiovisual stories that voice ways of knowing and being and are inclusive of art, are creative opportunities in which communities could take ownership and be highly engaged. Hughes et al additionally stressed the need for Cultural Safety audits and continuity of service in situations in which health care providers were noted to lack attention to privacy and often spoke in a highly alienating manner using complex medical language.

Nelson et al further addressed the effectiveness of a home-based kidney education program for the Zuni Pueblo, an indigenous people located in New Mexico, United States, that was delivered by community health representatives. The randomized clinical trial study assessed the effectiveness of home-based learning and treatment interventions developed in conjunction with the Tribal Advisory Panel and cultural protocols. Community health representatives, members of the Zuni Tribe who spoke Zuni, provided home visits and blood testing with results directly in the home. The community health representatives also sent positive health messages to participants by text. In addition, consultations occurred monthly through telemedicine with physicians and other service providers. Similarly to the articles by Richels et al, Hughes et al, and Jansen et al, the study by Nelson et al highlights how home-based care using local culturally consistent resources can improve treatment adherence and quality of life.

Walker et al completed a systematic review of qualitative studies related to indigenous experiences, perspectives, and values regarding kidney transplantation with participants from Australia, New Zealand, Canada, and the United States. A recurring theme that is shared with the articles by Richels et al, Hughes et al, and Jansen et al was the lack of patient engagement in kidney health care decision making, including prioritizing transplantation. Moreover, the review highlights issues with trust within the health care system and the need to incorporate traditional ways to foster kidney organ donation and transplantation. Overall, the need to further Cultural Safety and eliminate ignorance and prejudice was a finding shared by Richels et al, Hughes et al, and Jansen et al.

Another study conducted by Walker et al in 2012 involved 11 New Zealand nurses in telephone interviews concerning effective predialysis care. The qualitative research related mainly to the indigenous population, which is significantly overrepresented in those requiring kidney replacement therapy. Four themes emerged from the interviews revolving around time, culturally specific care, health care team relationships, and issues within nursing practice. As apparent in the publications by Richels et al and Hughes et al, the need for interpreters and culturally appropriate and indigenous-specific resources was pinpointed. Further, there were recommendations for “having cultural input into changes in health service systems; nurses having better access to and engagement with culturally appropriate social workers and cultural support personnel; and the promotion of kidney nursing to Ma ¯ori and Pacific students.”22(p31) The study also emphasizes the need for increased and consistent indigenous engagement within all sectors related to kidney care, including health care education and administrative and organizational systems.

Systemic Issues, Barriers, and Access

Conway et al offered insights into the perspectives of indigenous people and staff who are involved with hemodialysis occurring on a mobile bus that travels to remote areas of Australia. The qualitative study expressed the pivotal significance of land and cultural attachments to place of origin for indigenous people. Globally, indigenous people are frequently required to travel vast distances for dialysis and are often even required to relocate. Such detachments from family, community, and place result in adverse consequences related to grief and loss. Being separated from country often means the loss of elders for community, which is critical to cultural continuance. Elders are critical to a community healing from a traumatic history; they provide a sense of identity and maintain relationality. Conway et al further demonstrated that when elders receive dialysis at home, the community is strengthened because well-being through traditional practices is sustained and shared with the younger generations. With closer proximity to home, relationships with health care staff improved. Health care providers working in remote areas became more attuned to the relevance of cultural traditions to community well-being and the necessity of accessible care for overall community health.

Reilly et al performed a systematic review concerning clinical evidence of chronic kidney disease programs for indigenous people in Australia, New Zealand, Canada, and the United States. Components of these programs included embedding Cultural Safety through indigenous health workers within primary care services, addressing accessibility and continuity of care, furthering education consistent with maintaining local culture, and community ownership of programs. The article pointed to the high turnover of health care providers as more problematic than a lack of overall funds. Despite having sufficient funding, the continuum of care is adversely affected by the inability to retain health care providers. A solution proposed was to expand the number of indigenous health workers and increase capacity for their involvement in decision making. Supporting community ownership of health was connected to improving prevention activities that ultimately can reduce the burden of chronic diseases and associated costs.

The high turnover rate of health care providers, with concerns regarding confidentiality and embarrassment, as well as difficulties accessing medical care that required expensive transportation, were also discussed by Shah et al. This study investigated barriers to health care for people of the Zuni Pueblo, an indigenous people located in New Mexico. Community health representatives, trusted members of the community, were involved in focus groups. In close knit communities, members often had difficulty keeping their health conditions personal. For example, when attending public health events related to managing obesity, members risked criticism and unwanted attention to personal issues by others in the community. This attention could also foster self-guilt as being the cause of one’s illness. Relationships with health care providers were adversely affected by high turnover rates of providers and having to start again with explaining personal histories. Difficulties securing reliable transportation to medical facilities and pharmacies were also noted for those without cars or lacking support for transportation.

Sicotte et al described the provision of tele-hemodialysis services in 2 James Bay Cree communities in Canada through a quantitative pre-post study design involving 19 participants requiring hemodialysis. The telemedicine component allowed ongoing care and monitoring between health care providers and nephrologists with the person needing dialysis. The study found that tele-hemodialysis support reduced the burden associated with travel and the requirement for onsite health care providers that historically have had a high turnover rate. The authors recommended a qualitative study to determine the social and quality-of-life impacts for the recipients of care. This study highlighted tele-hemodialysis as an innovative solution with the potential to alleviate the issue of accessibility, transportation, and high staff turnover rates.

Addressing Legacies of Colonialism for Health Care Providers

A study by Rix et al asserted a Culturally Safe approach in which storying was prioritized and indigenous people themselves directed their own health care. The article further addressed victim blaming and racism through “relational accountability that incorporates respect, responsibility and reciprocity.”27(p2) The authors described a self-reflective journey through journaling that can expose harmful assumptions and stereotypes aligned with a Eurocentric system. Another qualitative study by Rix et al explained that Cultural Safety “will require more than just talk; it needs intensive listening and taking on board what Aboriginal people are saying.”28(p15) Their recommendation was for indigenous people from the community to be closely involved in kidney health care and education for mainstream health care providers. Focusing on to 2-way understanding strengthened relationships and encouraged respect for cultural or traditional worldviews as distinguished from mainstream approaches. This occurred by having indigenous health workers within dialysis units to provide an important cultural connection and presence for indigenous people receiving dialysis. Two-way understanding extended to having paid Elders involved in cultural training of nonindigenous health workers and including family members.

Kelly et al described a collaborative activity involving nurses who revised a kidney course designed for nurses who care for indigenous people in Australia. Case studies of patient journeys were anonymized and used by experienced nurses to illustrate culturally appropriate care to student nurses. Expert nurses were aligned with Cultural Safety as conceptualized within Benner’s model of competence stages. Cultural humility and Cultural Safety concepts were also distinguished. Cultural humility was defined as aligning with patient as expert and with self-reflection within an interpretative realm whereas Cultural Safety is aligned with “a critical social justice/equity/social determinants of health framework.”29(p110) Although the case studies stemmed from indigenous experiences, the study addressed the need for ongoing indigenous involvement in reviewing the overall course and its framework.

Walton used grounded theory to address spirituality through narratives and stories from 21 indigenous people in the context of dialysis care. From the narratives, the 4 themes of Honoring Spirit, Healing Old Wounds, Connecting With Community, and Suffering were conceptualized as a Sacred Circle model with approaches suggested for staff or health care providers. The themes were reflective of Cultural Safety concepts that prioritize ways of knowing and being. Honoring Spirit involves identifying and respecting religious or traditional practices and beliefs, smudging within the care unit, and supporting the use of meaningful items or symbols in prayer while receiving dialysis care. In Healing Old Wounds and Connecting With Community, the emphasis was on listening and sharing stories, expressing emotions respectfully and supporting traditions of prayer and family gatherings, and inquiring about relations and community. In Suffering, the recommendations included fostering dialysis education respectful of cultural ways, including family and community. Walton explained that participants went through phases of suffering, including asking why they had to become sick, experiencing periods of illness, repelling dialysis, debating between choices of life or death, praying for health, and persevering through dialysis for family. Providing comfort through traditional approaches was important to participants within dialysis units.

Another related study by Walton linked partnerships between nephrology and academic centers with furthering cultural care. A 1-hour presentation describing the Sacred Circle Model was followed by completing a critical reflection of a case study. Pre-post surveys identified changes in attitudes and beliefs for students who participated. Qualitative analysis of post surveys identified themes that included “approaching the patient with an open mind; developing trust; assessing beliefs, culture, and knowledge; educating and re-educating with patient and family; convincing the patient to have dialysis; and creating a sacred space.”30(p21) Some of the study outcomes included furthering open mindedness, trust building, and striving to understand beliefs. The aforementioned articles and the research by Walton suggest the need not only for approaches to promote supportive and respectful care, but also for education of health care providers that is consistent with indigenous ways of being and knowing.27, 28, 29, 30, 31

Discussion

Culture Safety requires a lens that genuinely reflects on the relationship and balance of power between care providers and recipients. In this regard, most articles in this review identified the need to build trust within indigenous kidney care in the 4 countries of Australia, Canada, New Zealand, and the United States. The articles included for this review were pertinent to the focus of Cultural Safety within indigenous kidney care. Overall, there was a paucity of articles that addressed the research question.

The publications by Richels et al, Hughes et al, Jansen et al, Nelson et al, and Walker et al, were consistent with the concept of Cultural Safety within kidney care and expressed relationality, engagement, and health care self-determination. Relationality and engagement were critical to health and well-being; these emerged as a community strength significant to those in need of dialysis care. Having the family and community close by and involved in shaping the care to be provided was vital to respectful care.17, 18, 19, 20 Specific to health care determination were the articles by Hughes et al, Richels et al, and Walker et al, in which participants expressed that it was crucial that they, in addition to family members and communities, be more involved in decision making. For example, the systematic review by Walker et al supported the acceptability of kidney transplantation; however, there were concerns when the subject of transplantation remained elusive within discussions with health care providers. Community engagement and health care self-determination also became apparent as a way to further trust. This was evident in the articles by Nelson et al and Walker et al, who highlighted the need for indigenous health workers who were familiar with the community’s language and culture to support community-based kidney care. Systemic issues, barriers, and access are reflected within the articles by Conway et al, Reilly et al, Shah et al, and Sicotte et al. Accessibility issues overlap with continuity of care in which indigenous communities struggled to maintain a stable workforce of health care providers necessary to the provision of kidney care., Innovative ways to improve accessibility to remote dialysis included a mobile dialysis unit and tele-hemodialysis., The benefits of community ownership of care were emphasized in these articles, as well as care provided by fellow community members familiar with language and ways of being.23, 24, 25, 26

The studies within the cluster addressing legacies of colonialism for health care providers speak to the critical necessity for health care providers to learn indigenous ways of being and knowing as provided by elders, indigenous persons with kidney disease, their families, and communities themselves.27, 28, 29, 30, 31 Health care providers may benefit from journaling and case studies to allow a deeper understanding and appreciation of how colonialism has shaped health care for indigenous people., Another recommendation essential to trust building was the need to listen to those with kidney disease within comforting surroundings that afford respectful listening and privacy. Accommodating cultural traditions within dialysis units builds trust and exemplifies respect. At the same time, it is important to not assume that all indigenous people have the same belief system.

A narrative review methodology with a systematic database search was chosen given the dearth of articles and the broad focus related to the term Culturally Safe care specific to kidney disease within indigenous contexts. Although there was a multitude of records related to culture, it was a challenge to garner those specific to our focus. To glean meanings from the existing literature on Cultural Safety and kidney disease required a flexible approach toward the literature. Given that we included a variety of articles including qualitative studies, the assessment for methodological rigor or quality of the studies was limited to consideration of the quality of the journal and whether it was peer reviewed.

Although Cultural Safety is a term that has been in the literature for some time and is increasingly being referred to, particularly in Australia, New Zealand, and Canada, its expression within kidney care still requires further understanding and delineation. The studies involved in this narrative review solidify that indigenous-determined care and engagement is critical toward improving kidney health outcomes. A multifaceted effort is required to support the recruitment of indigenous students and health care workers. Kidney educational programs require health care providers to engage in learning about systemic racism and the legacy of colonialism. Additionally, indigenous health workers and social workers need to be involved in decision making and advocating for those needing kidney replacement therapy or transplantation. Indigenous persons with kidney disease, their families, elders, and community groups can also participate in enhancing and creating tools with mainstream providers for kidney care and kidney disease prevention. Given the overall burden of kidney disease, it is important to fund and support indigenous community members and mainstream health care providers in designing kidney care programs together that instill language and traditional protocols into accessible Culturally Safe care. In addition, there is a need for ongoing indigenous research that evaluates and sustains Culturally Safe indigenous kidney care and chronic disease prevention programs. It is critical that health care authorities engage communities and care recipients in decision making, provide a respectful time and space to listen, and enable indigenous-driven traditional protocols and approaches within highly technical dialysis units and nephrology services.