3.2 Social Determinants of Health and Cultural SafetyV2
Many factors will have an influence on health, including a client’s health practices such as managing and treating health conditions. These health practices are significantly impacted by social and economic factors, which must be considered when providing care to a client. The social determinants of health “refer to a specific group of social and economic factors within the broader determinants of health. These relate to an individual’s place in society, such as income, education or employment” (Public Health Agency of Canada, 2024). Other experiences such as discrimination, racism, and historical trauma are also important social determinants, especially for certain groups such as Indigenous Peoples, the 2SLGBTQI+ community, and Black Canadians. The Public Health Agency of Canada has identified fourteen determinants of health including:
- income and income distribution,
- education,
- unemployment and job security,
- employment and working conditions,
- early childhood development,
- food insecurity,
- housing,
- social exclusion,
- social safety network,
- health services,
- Indigenous status,
- gender,
- race, and
- disability
In nursing, and the broader healthcare field, these are important considerations when caring for clients. Nurses should understand how these determinants of health can have an impact on clients’ quality of life and ability to access healthcare, including understanding their health condition and treatments, (e.g., medications).
Example in Practice:
A nurse works in a primary healthcare clinic and is with a client reviewing their medications for a number of health issues. The client nods and appears to understand the discussion and the importance of the medications. The client returns two weeks later, and the nurse learns that the client did not fill the prescriptions. One assumption s that they are being non-compliant, but a lack of medication adherence can be due many factors:
- Could it be a lack of money to buy the medications?
- It is their inability to get the pharmacy to get the prescription filled?
- Was it a language barrier and they were being polite by nodding?
- Did they not understand due to low literacy level or a language barrier?
Socioeconomic factors can prevent a client from receiving the care necessary to improve their health. The nurse should investigate barriers to care by using simple, non-judgmental language and working with the client to discuss strategies. “Nurses must assess and respect the client’s values, beliefs, personal preferences, language, learning needs, abilities, mental state, and level of understanding, to support the client (or their substitute decision maker) to be an active participant in making informed decisions.” (British Columbia College of Nurses & Midwives, n.d.).
Along with determinants of health, Canadian nurses must also understand the cultural influences around medication use. Canada has become increasingly diverse in the last century. According to Statistics Canada in 2016, approximately 7,674,580 people in Canada fit into the visible minority population in Canada. Though health indicators such as life expectancy and infant mortality have improved for many, some minorities experience a disproportionate burden of preventable disease, death, and disability compared with non-minorities (Centers for Disease Control and Prevention, 2017).
To address this diverse population and to uphold the values of cultural diversity and respect for all peoples, the Canadian Nurse’s Association (2025) Code of Ethics for Nurses has recently been updated to highlight the ethical values nurses require in today’s health care setting.
For example:
- Value 1: Honouring the Dignity and Autonomy of all People.
- Value 4: Pursuing Truth and Reconciliation.
These values, among others, help guide nurses in promoting ethically competent nursing practice.
Cultural Safety
Cultural safety is defined as an outcome-based, respectful engagement that addresses power imbalances through societal and health care systems lenses. Being culturally safe in a nurse’s practice provides an opportunity to fully engage in caring, where people feel safe when receiving care and are free from racism and/or discrimination (First Nations Health Authority, 2016).
When providing culturally safe care, nurses must recognize the critical component of cultural humility. Cultural humility is self-reflection of our own personal biases as well as recognition of other systematic biases. When we change our lens from one of using our nursing role as a power position, we need to consider fostering a relationship between ourselves and our clients that is built on trust and openness (First Nations Health Authority, 2016).
To help nurses achieve this goal, we turn to our practice standards for direction. British Columbia College of Nurses and Midwives (BCCNM, 2016) has developed the practice standard, Indigenous Cultural Safety, Cultural humility and Anti-Racism, with six core concepts and principles, beginning with a self-reflection exercise and ending with a strengths-based and trauma-informed practice. For the full practice standard, go to BCCNM’s (n.d.) Indigenous Cultural Safety, Cultural Humility, and Anti-Racism page.
When administering medication, nurses build trust with their clients and recognize that each client has a unique life and cultural history. Nurses must follow their scope of practice for medications but also recognize that it is vital to have their clients become key drivers in their own care. To create this relationship, nurses must consider:
- cultural barriers that could impact the full engagement of the client;
- language barriers;
- previous negative experience with a healthcare team; and
- distrust of the healthcare system.
Figure 3.2a Diversity of clients in health care
Utilizing open communication through the skills of relational practice allows nurses to develop a partnership in decision making. Listening to the needs of the client initiates an open discussion that improves health outcomes through medication adherence and an understanding of key factors (First Nations Health Authority, 2016).
Relational practice
Relational practice refers to the nurse’s ability to communicate within a deeper context, such as building a foundational health relationship that promotes effective nursing care. The interpersonal connection transcends and changes shape to meet the current needs of the client (College of Licensed Practical Nurses of Alberta, 2021)
References
British Columbia College of Nurses & Midwives. (n.d.). Indigenous cultural safety, cultural humility, and anti-racism. https://www.bccnm.ca/NP/PracticeStandards/Pages/CulturalSafetyHumility.aspx
British Columbia College of Nurses & Midwives. (n.d.). Medication. https://www.bccnm.ca/RN/PracticeStandards/pages/medication.aspx
Canadian Nurses Association. (2025). Code of ethics for nurses. https://www.cna-aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-ethics
Centers for Disease Control and Prevention. (2017). Health equity – Minority health. Internet Archive. https://web.archive.org/web/20170127011807/https://www.cdc.gov/MinorityHealth/index.html
College of Licensed Practical Nurses of Alberta. (2021) Relational practice self-study course. Internet Archive. https://web.archive.org/web/20210625125722/https://studywithclpna.com/relationalpractice/
First Nations Health Authority. (2016). Creating a climate for change [PDF]. https://www.fnha.ca/Documents/FNHA-Creating-a-Climate-For-Change-Cultural-Humility-Resource-Booklet.pdf
Public Health Agency of Canada. (2024). Social determinants of health and health inequalities. Government of Canada. https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html
Statistics Canada. (2016). Immigration and ethnocultural diversity: Key results from the 2016 census. Government of Canada. https://www150.statcan.gc.ca/n1/daily-quotidien/171025/dq171025b-eng.htm
Image Attributions
Figure 3.2a Equity-diversity. https://pixabay.com/illustrations/friends-equality-diversity-rainbow-7822175/
