1

Exploring Cultural Competence of Registered Midwives in British Columbia, Canada
by
KIMBERLY L. ROLLE, BScN
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE DEGREE OF MASTER OF NURSING
School of Nursing
Thompson Rivers University

Primary Supervisor
Dr. Catherine Ringham, RN, BSN, PhD, CNeoN(c)
Committee Members
Dr. Melba D’Souza, RN, PhD, CCNE
Dr. Tracy Christianson, RN, DHEd, CCNE

23 July, 2025

©Kimberly L. Rolle 2025

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Land Acknowledgement
Thompson Rivers University campuses are on the ancestral lands of the Tk̓emlúps te Secwépemc
(Kamloops campus) and the T̓éxelc (Williams Lake campus) within Secwepemcúl̓ecw, the
ancestral and unceded territory of the Secwépemc. The region TRU serves also extends into the
territories of the St’át’imc, Nlaka’pamux, Nuxalk, Tŝilhqot'in, Dakelh, and Syilx peoples.

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Acknowledgements
I would like to honour my heavenly Father God: With a grateful heart, thank you, my
Creator and Friend for being everything that I needed and more and giving me the grace and
wisdom to start and finish every milestone in my life.
Zion H. Roberts: Thank you, son, for your continued emotional support and for sharing
tears of joy with me during this rigorous nursing journey from the first mention of attending
nursing school in The Bahamas to pursuing my Master of Nursing degree in Canada. I love you.
To mom, Vernell D. Rolle, my six siblings, my cousins Shantia and Cory, other relatives and
friends in The Bahamas: Thank you for your love, support and encouraging words.
Dr. Clyde A. Munnings: Thank you for always believing in me and faithfully supporting
me in all of my endeavours over the past 15 years, especially when I leaped to pursue a nursing
career, plus studying during a pandemic and not to mention pursuing my Master of Nursing
degree in Canada.
Primary Supervisor and Committee members: Thank you, Dr. Catherine Ringham, Dr.
Melba D’Souza, Dr. Tracy Christianson and Dr. Rani Srivastava, for the intense mentoring,
coaching and advising, always challenging me to press toward a higher level of thinking and
application while encouraging me to keep pressing forward to my bigger goal and achieving my
graduation.
TRU Elders, management and staff of TRU Indigenous Education, All My
Relations/Knowledge Makers, Office of the Vice-President Research, Motion Church family:
Thank you for welcoming me to Kamloops, your continued love, prayers and support.

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Abstract
Culture is a dynamic force that fundamentally shapes the perinatal experience. In British
Columbia, Canada, where cultural diversity continues to evolve, the ability of healthcare
professionals to deliver culturally respectful and appropriate care has never been more critical.
Despite this, significant barriers persist for culturally diverse patients seeking maternal health
services, many of whom report negative experiences and inequitable outcomes. This qualitative
study explores how Registered Midwives in British Columbia perceive, understand, and apply
cultural knowledge in their care of patients from diverse backgrounds. Using Srivastava’s
Culture Care Framework as a guiding structure, eight semi- structured interviews were
conducted with practicing midwives between May and October 2024. Directed Qualitative
Content Analysis of these interviews revealed four key themes: (1) perception of culture; (2)
professional development and training; (3) cultural influences on midwifery care; and (4)
delivery of midwifery care. These themes highlight both the strengths and limitations of current
practice, including midwives’ commitment to provide custom- tailored, respectful care as well as
the lack of consistent training, systemic support, and standardized tools to assist in culturally
competent practice. This study contributes to a deeper understanding of how culture is enacted
by midwives in clinical settings. It highlights the need for intentional strategies to integrate
cultural competence into midwifery education, policy, and care frameworks. Implications for
nursing and midwifery include the integration of culture- informed curricula, interdisciplinary
collaboration, and policies that support equity and inclusion in maternal care. Ultimately, these
findings provide valuable insights to inform practice, research, and policy efforts aimed at
enhancing perinatal outcomes for all patients, regardless of their cultural background.
Keywords: cultural competence, registered midwives, midwifery, cultural safety, perinatal care,
qualitative research, British Columbia

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Table of Contents

Land Acknowledgment ....................................................................................................... 2
Acknowledgements ............................................................................................................. 3
Abstract ............................................................................................................................... 4
List of Tables....................................................................................................................... 9
List of Figures ................................................................................................................... 10
Chapter One ...................................................................................................................... 11
Introduction ....................................................................................................................... 11
The Profession of Midwifery ............................................................................................ 12
Demographic Profile of Canada and British Columbia .................................................... 13
Indigenous Peoples ....................................................................................................... 15
Call for Cultural Competence in the Canadian Health Care System ............................ 16
Statement of the Problem .................................................................................................. 16
Research Questions ........................................................................................................... 17
Purpose of the Study ......................................................................................................... 18
Significance of the Study .................................................................................................. 19
Definition of Key Terms ................................................................................................... 20
Researcher’s Positionality ................................................................................................. 21
Chapter Summary.............................................................................................................. 23
Chapter Two ..................................................................................................................... 24
Review of the Literature ................................................................................................... 24
Search Strategy ................................................................................................................. 24
Search Plan and Record .................................................................................................... 24
Database Selection ............................................................................................................ 25
Search Strategies in Bibliographic Databases ................................................................... 26
Theme 1. Cultural Competence in Healthcare .................................................................. 27
Theme 2. The emergence of Cultural Competence in Midwifery Care ............................. 31
Theme 3. Patient Experiences in Maternal Health ............................................................ 35
Notable Findings: Racism and discrimination .................................................................. 38
Theoretical and Epistemological Frameworks .................................................................. 39
Cultural Sensitivity............................................................................................................ 40
Cultural Knowledge .......................................................................................................... 41

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Cultural Resources ............................................................................................................ 42
Cultural Care Action and Decision Modes ........................................................................ 42
Chapter Summary.............................................................................................................. 46
Chapter Three.................................................................................................................... 47
Methodology ..................................................................................................................... 47
Research Design Overview ............................................................................................... 47
Study Participants ............................................................................................................. 49
Recruitment Process .......................................................................................................... 49
Participant Selection ......................................................................................................... 50
Ethical Considerations and Procedures for Protection of Human Subjects .................. 51
Data Collection ................................................................................................................. 54
Data-Collection Procedures .............................................................................................. 54
Interview Process .......................................................................................................... 54
Data Recording and Data Transformation......................................................................... 55
Data-Analytic Strategies ................................................................................................... 56
Step One: Developing a Formative Categorization Matrix............................................... 57
Step Two: Development of Coding Template ................................................................... 58
Step Three: Specifying the Unit of Analysis ..................................................................... 58
Step Four: Immersion in the Data ..................................................................................... 59
Step Five: Data Condensation and Abstraction (Coding Process) .................................... 59
Step Six: Data Display ...................................................................................................... 60
Data Analysis and Interpretation Beyond the CCF ........................................................... 60
Trustworthiness................................................................................................................. 62
Chapter Summary.............................................................................................................. 63
Chapter Four ..................................................................................................................... 64
Findings............................................................................................................................. 64
Demographic Profile of Participants ................................................................................. 65
Theme One: Perception of Culture ................................................................................... 66
Description of Culture....................................................................................................... 66
Description of Cultural Competence ............................................................................. 68
Description of Cultural Safety ...................................................................................... 71
Description of Cultural Sensitivity................................................................................ 73

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Theme Two: Professional Development and Training ...................................................... 75
Cultural Knowledge .......................................................................................................... 76
History and Culture of Canada...................................................................................... 79
Educational Modes of Delivery .................................................................................... 79
Cultural Resources ............................................................................................................ 80
Individual Resources ..................................................................................................... 80
Organizational Resources.............................................................................................. 81
Professional Resources ................................................................................................. 81
Theme Three: Cultural Influences on Midwifery Care ..................................................... 81
Consider the Cost of Care ............................................................................................ 82
Incongruence During Care ............................................................................................ 84
Pressures Across Care ................................................................................................... 88
Theme Four: Delivery of Midwifery Care ........................................................................ 90
Phase One: Assessment................................................................................................. 93
Phase Two: Care Approaches ........................................................................................ 94
Phase Three: Documentation ........................................................................................ 96
Phase Four: Goals of Care ............................................................................................ 97
Phase Five: Referrals .................................................................................................... 98
Chapter Summary.............................................................................................................. 99
Chapter Five .................................................................................................................... 100
Discussion ....................................................................................................................... 100
Theme One: Perception of Culture ................................................................................. 100
Interpretation of Cultural Competence........................................................................ 101
Interpretation of Cultural Safety ................................................................................. 102
Interpretation of Cultural Sensitivity .......................................................................... 103
Theme Two: Professional Development and Training .................................................... 104
Cultural Knowledge ........................................................................................................ 104
History of Colonialism in Canada............................................................................... 104
Cultural Resources .......................................................................................................... 105
Individual Resources ................................................................................................... 105
Organizational Resources............................................................................................ 106
Professional Resources ............................................................................................... 106

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Theme Three: Cultural Influences on Midwifery Care ................................................... 106
Consider the Cost of Care ............................................................................................ 107
Incongruence During Care ........................................................................................... 108
Pressures Across Care .................................................................................................. 108
Theme Four: Delivery of Midwifery Care ...................................................................... 110
Limitation of Study ......................................................................................................... 112
Contribution to Field of the Study .................................................................................. 114
Nursing Implications ...................................................................................................... 114
Significance to Education ........................................................................................... 115
Significance to Nursing Practice................................................................................. 116
Significance to Future Nursing Research ................................................................... 117
Significance to Health Policy ..................................................................................... 118
Recommendations for Future Study................................................................................ 119
Conclusions..................................................................................................................... 120
Knowledge Translation ................................................................................................... 121
References ....................................................................................................................... 124
Appendix A: Research Ethics Board Approval - TRU ................................................... 147
Appendix B: Certificate of Ethical Approval – Interior Health ..................................... 148
Appendix C: Institutional Approval – Interior Health .................................................... 149
Appendix D: Recruitment Poster .................................................................................... 150
Appendix E: Invitation Letter to Midwifery Organizations ........................................... 151
Appendix F: Invitation Letter to Registered Midwives .................................................. 152
Appendix G: Informed Consent Form ............................................................................ 153
Appendix H: Demographic Profile ................................................................................. 153
Appendix I: Semi-Structured Open Inquiry Interview Guide ........................................ 158
Appendix J: Chart for Searching Literature.................................................................... 161
Appendix K: Coding Template ....................................................................................... 163
Appendix L: Tool for Demographic Profile Questions .................................................. 166
Appendix M: Example of Coding................................................................................... 167
Appendix N: Curriculum Vitae ...................................................................................... 169

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List of Tables
Table 1: Ethnic and Cultural Origins in Canada and British Columbia ...................................... 14
Table 2: Operational Coding Template........................................................................................ 57
Table 3: Demograph Profile of Participants ................................................................................... 66
Table 4: Developing a Birth Plan in Midwifery Practice ............................................................. 92

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List of Figures
Figure 1. Culture Care Framework ............................................................................................... 43
Figure 2. Cultural Competence of Registered Midwives in British Columbia, Canada ............... 65
Figure 3. Thematic Map of Theme Two: Professional Development and Training ..................... 76
Figure 4. Symbolic Representation of Cultural Influences on Midwifery Care ........................... 82
Figure 5. Five-Phase Cultural Considerations of Care Model ...................................................... 91

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Chapter One
Introduction
A newborn does not choose a culture but is born into one. For this reason, culture should
be taken into consideration by midwives during pregnancy, childbirth and the post-natal period
to establish high-quality patient-centered care. It is vital for midwives serving multicultural
populations to understand how the values, beliefs and traditions of patients vary. For culturally
diverse patients, culturally congruent care during this life- changing phase is crucial because
culture is influential and dynamic. In Canada, midwives are independent healthcare providers
who provide care for pregnant individuals, families and communities in maternal health settings
(British Columbia College of Nurses and Midwives, 2024; Thompson, 2020). The birth of
newborns into diverse culture existed for past generations and for midwives, care begins from the
first prenatal visit to the last postpartum visit after birth, with visits often lasting for 30-60
minutes (Midwives Association of British Columbia [MABC], 2025). Therefore, midwives
should integrate culture into the "birth plan" of culturally diverse patients to provide highquality, culturally congruent care (D'Souza & Leslie, 2023).
Valuing cultural diversity requires respecting cultural characteristics among multicultural
populations, such as ethnicity, religion, race, and gender, among others (Udod & Racine, 2018).
The term "culture" originated in the field of anthropology and refers to the values, beliefs,
customs, and traditions that are passed down to individuals, families, and communities through
teaching and learning (Leininger, 1995). According to Spradley (1979), culture is shared
knowledge that is meaningful, retained and modified within and amongst various social groups.
In nursing, Leininger (1997), a renowned pioneer, emphasized that while care and culture
may not be overtly visible, both are vital in the field of nursing; hence developed the term culture
care and the Culture Care Theory. Leininger held that care should be studied systematically from

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a holistic cultural perspective to discover, improve, and provide culturally congruent care that
benefits the patient (Marriner-Tomey & Alligood, 2006). Moreover, Leininger held that culture
care encompasses considering the patient's cultural background and incorporating their values,
beliefs, customs, and traditions into the care goals (Leininger, 1997). Leininger (2002) coined the
term culturally congruent care in the 1960s with the Theory of Culture Care Diversity and
Universality and I have defined the term in this study under the heading “Definition of Key
Terms”.
The Profession of Midwifery
Historically, births in urban communities were attended by doctors in hospitals, whereas
in rural communities, midwives were typically present (D'Souza & Leslie, 2023). A midwife is a
healthcare professional who collaborates with pregnant individuals, families, and communities
during the perinatal period to provide care and support to both the pregnant person and their
newborn (British Columbia College of Nurses and Midwives, 2025b; D'Souza & Leslie, 2023;
International Confederation of Midwives, 2024). Midwifery is the practice of providing care,
skills, and knowledge to pregnant individuals by a midwife. (World Health Organization, 2025a).
Midwives possess advanced specialized knowledge in midwifery and can also be referred to as
“midwives” or “registered midwives” (British Columbia College of Nurses & Midwives, 2025a).
They are described as experts in perinatal care and adhere to seven key principles which include
professional autonomy, partnership, continuity of care provider, informed choice, choice of birth
setting, evidence-based practice and collaborative care (Canadian Midwifery Regulators Council,
2022).
Pregnancy and childbirth are life-changing events; therefore, midwives must provide
culturally congruent care that is tailored to and beneficial for the patient, their family, and their

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community (D'Souza & Leslie, 2023).
Registered Midwives (RMs) in BC are independent healthcare professionals in Canada's
healthcare system who provide holistic community based primary care, prenatal care (before the
baby's birth), deliver the baby and provide postpartum care (after baby delivery) and newborn
care for up to six weeks after birth (Midwives Association of British Columbia, 2025; Thompson,
2020). Registered midwives in BC earn, on average, $1,400 per course of care (in the first year)
and $3,132 (with experience) per midwifery service provided (Canadian Midwifery Regulators
Council, 2022; Hanson et al., 2013; Thiessen et al., 2020; Thompson, 2020). It is essential to
understand that in the Canadian healthcare system, there is a shortage of midwives, and the
salaries of RMs can indirectly impact cultural competence by influencing the diversity of the
midwifery workforce and the availability of culturally safe care (Canadian Midwifery Regulators
Council, 2022; Hanson et al., 2013; Thiessen et al., 2020; Thompson, 2020). Additionally, RMs
in BC practice independently as self-employed healthcare professionals and are not employees of
the BC government; instead, they are paid a flat fee per care provided (BCCNM, 2025).
Pregnancy and childbirth are life-changing and defining moments. Midwives play a
significant role in providing culturally congruent care that meets the cultural needs of patients,
families, and communities (D'Souza & Leslie, 2023). Considering the changing demographics of
Canada and recognizing that pregnancy and childbirth are life-changing events, it is essential to
explore the cultural competence of midwives in BC.
Demographic Profile of Canada and British Columbia
Globally, Canada is recognized as a multicultural or "mosaic" country, being the first
country in the world to enact the Canadian Multiculturalism Act in 1988 (Berry, 2020). The
Multiculturalism Act is an intrinsic characteristic of Canada's identity, promoting diversity and

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equality in the country (Government of Canada, 2025). Canada has an estimated population of 40
million people, of which immigrants make up 23% of the population (Government of Canada,
2024). Prior to the last five decades, most immigrants came from Europe and since then
immigrants have come from Asia and Africa (Statistics Canada, 2022). Additionally, migration to
Canada is projected to exceed 80% in the future (Statistics Canada, 2018).
According to Statistics Canada (2022a), there are 450 ethnic and cultural origins in
Canada and BC, and they are summarized in Table 1. The concept of visible minority is utilized
by Statistics Canada and is defined as "persons, other than Aboriginal peoples, who are nonCaucasian in race or non-white in colour (Government of Canada, 2023b). British Columbia is
described as one of the most ethnically diverse provinces in Canada, with a population of five
million (Statistics Canada, 2022a). Additionally, there are an estimated 40,000-60,000 births per
year in BC that occur at home, birthing centres, or hospitals (Thompson, 2020).
Table 1
Ethnic and Cultural Origins in Canada
Cultural Group
Canada (%)
Canadian, French and British Isles
15.6
[English, Scottish and Irish]
European (Italian, German, Ukrainians, 52.5
Polish and Dutch);

Chinese*
Indian (India)
Filipino
South Asian*
Black*
Norwegian
Russian
First Nations (North American Indian)
Welsh
Swedish

4.7
2.6
2.6
7.1
4.3

British Columbia (%)

9.3, 6.4, 20.7, 15.8 and 12.8
respectively
3.3, 11.0, 4.3, 2.7 and 3.9 respectively
10.5
5.6
3.5
2.8
2.5
2.1
2.1
2.1

Note: * = visible minority group (Statistics Canada, 2018, 2022, 2023)
In a society composed of diverse cultural backgrounds, midwives must be aware of the

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needs of culturally diverse patients during the perinatal period.
Indigenous Peoples
It is also essential to understand the origin and historical background of Indigenous
peoples, as they were the first inhabitants in Canada, comprising three distinct groups: First
Nations, Métis, and Inuit (Parrott, 2023). In 2021, 58.0% (1,048,045) were First Nations, 34.5%
(624,215) were Métis, and 3.9% (70,540) were Inuit (Statistics Canada, 2022b). Historically,
Indigenous peoples were considered wards of the state, according to the Indian Act, which led to
their demise due to epidemics of smallpox, tuberculosis, cultural genocide, and colonization by
the Europeans (Bearskin et al., 2023; Greenwood et al., 2017). Colonialism generated a vicious
cycle of health inequities across social determinants of health, Indigenous-specific racism,
marginalization and intergenerational trauma that continues to be felt today (Bearskin et al.,
2023; Greenwood et al., 2017; Minister of Health, 2018; Turpel-Lafond (Aki-Kwe), 2020;
Waschuk, 2018).
The ongoing struggle for self-determination encompasses areas such as justice, education,
health, and social services, as well as the revitalization of Indigenous culture, language,
medicine, and healing traditions, and the decolonization of Eurocentric ways (Bearskin et al.,
2023; Greenwood et al., 2017). Moreover, researchers have found limited strategies to improve
cultural competency for Indigenous peoples (Clifford et al., 2015; Rissel et al., 2023). Given
these points, culture matters. To better understand cultural influences on healthcare, it is
critically important to understand cultural competence in midwifery care for the diverse peoples
in Canada.

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Call for Cultural Competence in the Canadian Health Care System
The clarion call for cultural competence has resonated in the Canadian healthcare system
for decades, issued by governments, regulatory nursing bodies, and professional nursing
organizations. In 2018, the Canadian Nurses Association (CNA) published a position statement
highlighting the importance of cultural competence and outlining the roles of government,
employers, and individual nurses in delivering culturally competent care. Also, in 2020, the
Public Health Agency of Canada published national guidelines for healthcare professionals
providing maternity and newborn care, emphasizing the importance of delivering care with
cultural considerations for diverse populations to ensure the safety of mothers and babies
(Wagner et al., 2020).
Moreover, the Canadian Midwifery Regulators Council, the British Columbia College of
Nurses and Midwives (BCCNM), and the Canadian Association of Perinatal and Women’s
Health Nurses (CAPWHN) outlined the overall competencies and standards of practice required
and expected of midwives. Yet, how to develop, integrate and deliver cultural competence
remains enigmatic (Srivastava, 2023; Wiliamson & Harrison, 2010).
In midwifery care, cultural competence is a complex and multidimensional concept when
providing care to people with culturally diverse backgrounds. Cultural competence is not a task,
procedure, or goal, but a journey that is critical and should be seriously considered a nursing
priority by midwives in BC during the nurse-patient interaction with culturally diverse patients.
Statement of the Problem
Srivastava (2023) emphasized that culture is complex, and the process of cultural
competence involves unlearning former ways of doing, adopting new ways of knowing, and
implementing a pragmatic approach to care that incorporates cultural considerations into

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professional and ethical standards of practice. At the same time, D’Souza and Leslie (2023)
emphasized that it is crucial to acknowledge and incorporate culture when developing a birthing
plan.
There is strong evidence indicating that culturally diverse patients continue to experience
adverse childbirth outcomes and face barriers when accessing maternal health services
(Higginbottom et al., 2013b; Marriott et al., 2019; Niles et al., 2021; Smylie et al., 2021; Vang et
al., 2018; World Health Organization, 2019). Although there is a dire need for cultural
competence in healthcare, integration into midwifery practice remains challenging, unclear, and
empirical evidence on how to do so is limited (Marriott et al., 2020; Munns, 2021; Williamson &
Harrison, 2009).
As much as cultural competence plays a significant role in delivering midwifery care to
culturally diverse patients, research is scarce. There is a lack of evidence for the development of
clinical practice guidelines, protocols, policies, or care plans specifically on how to deliver
cultural competence into midwifery practice. This problem may be due to the limited research on
cultural competence in midwifery in BC, and little is known about how midwives deliver cultural
competence in nursing practice. Moreover, a review of the literature revealed that no prior
research has been conducted in Canada or BC to explore the cultural competence of midwives
registered and practicing in BC. Therefore, this study will explore the meaning of culture from
the perspectives of RMs in BC and examine how this knowledge is applied in midwifery practice
for culturally diverse patients.
Research Questions
My explorative-descriptive study explored four qualitative research questions:
1.

How do registered midwives (RMs) in British Columbia (BC)

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describe culture in midwifery practice?
2.

What cultural knowledge, skills and resources do RMs in BC utilize
to support the delivery of culturally congruent care in midwifery
practice?

3.

What are the cultural influences on midwifery care that inhibit
or support the delivery of culturally congruent care?

4.

How do RMs in BC integrate cultural considerations of care in practice?
Purpose of the Study

The overall purpose of this qualitative study is to explore the meaning of culture from the
perspectives of RMs in BC and to explore how knowledge is translated into midwifery practice
for culturally diverse patients. In this study, I have chosen the profession of midwifery because
midwives are autonomous healthcare professionals who provide holistic care for both mother and
baby in various healthcare environments (Canadian Midwifery Regulators Council, 2022). A
qualitative method was suitable for studying the meaning and application of the concepts of
culture, cultural safety, and cultural competence. Such research is integral to promoting
culturally congruent care in diverse, multicultural healthcare environments. The results from this
research may also be published in peer-reviewed journals and presented at conferences.
Additionally, opportunities may arise to promote attention to clinical practice guidelines,
recommendations, policies, and evidence-informed care plans that focus on cultural competence
in midwifery care.
The three cultural concepts defined above must be understood before developing cultural
competence, as this understanding lays the foundation for the theoretical framework used in this
study, known as the Culture Care Framework (CCF) (Srivastava, 2023). A description of the

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CCF will be provided under the heading “Theoretical Framework”. Given these points,
understanding the perception of these cultural concepts by RMs in BC is vital to meet the aim of
this study and to exploring how this knowledge is translated into midwifery practice when
providing care to culturally diverse patients.
Significance of the Study
Cultural competence is a broad and complex phenomenon, making this study essential for
deepening understanding in healthcare, particularly in midwifery. By identifying cultural
influences and evaluating the effectiveness of care approaches, this research can inform
curriculum development, birth plans, policies, and future studies to enhance health outcomes and
ensure high-quality care.
Governments, regulatory bodies, and professional organizations have undertaken
exceptional initiatives, including funding, issuing position statements, and developing culturally
inclusive health programs. These efforts have fostered cultural awareness over time. However,
despite these achievements, cultural competence remains a persistent challenge that continues to
affect the social, economic, and political well-being of culturally diverse patients (Government of
Canada, 2024b; World Health Organization, 2019).
The significance of this study is that when the perspectives of midwives about culture,
cultural competence and cultural safety are made explicit; sources of cultural knowledge
identified; cultural influences are explored historically, socially, economically and politically
coupled with a practical strategy for midwifery care the complexity of cultural competence can
be addressed and knowledge developed to address the current gap. The data collected from this
study can reinforce inclusive healthcare practices that strive to respect and address the diverse
cultural needs of patients.

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Definition of Key Terms
The following terms were used specifically in this study. Theoretical and conceptual
definitions are supplied.
Culture: “the learned shared and transmitted knowledge of values, beliefs, norms and lifeways
of a particular group that guides an individual or group in their thinking, decision and actions in
patterned ways” (Leininger, 1995, p. 60).
Cultural Safety: for the midwife is “understanding of Indigenous cultural birth issues (as a
means of building the midwife’s cultural awareness of these); and incorporating cultural
awareness into midwifery practice by initiating actions that support an Indigenous woman to feel
safe to access maternity care (as a means of developing culturally safe maternity care” (Marriott
et al., 2021).
Cultural Competence: is “a set of congruent behaviours, attitudes, and policies that come
together in a system, agency, or among professionals and enable that system, agency or those
professionals to work effectively in cross-cultural situations” (Srivastava, 2023, p. 18).
Registered Midwives: licensed health care professionals who provide maternity care services
(BCCNM, 2025)
Culturally Diverse Patients: refers to individuals with different cultural backgrounds receiving
health care from a healthcare professional during the perinatal period (Esegbona- Adeigbe,
2023). Cultural backgrounds may include but are not limited to ancestral origins, socioeconomic
status, religion and or physical limitations, just to name a few. The term diversity “recognizes the
difference among single cultures and identifies characteristics that are autonomous and distinct”
(Esegbona-Adeigbe, 2023, p. 5).
Maternal Health Settings: maternal health refers to “the health of women during pregnancy,

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childbirth and the postnatal period” in a facility that provides maternal health care such as a
hospital, clinic or birthing center (World Health Organization, 2025a).
Culturally Congruent Care: refers to “the use of sensitive, creative and meaningful care
practices to fit with the general values, beliefs and lifeways of culturally diverse patients “for
beneficial and satisfying health care” (Leininger and McFarland, 2002, p. 12).
Researcher’s Positionality
I am a Black woman, born in the Commonwealth of the Bahamas, where much of the
population is of African descent. During my years of formal schooling, I was not exposed to the
colonial history of my country until I attended university. It was then that I understood the Taíno
or Arawakan ancestors became extinct, leaving no survivors (Encyclopaedia Britannica, 2025). I
did not realize that this lack of historical knowledge impacted my understanding of the
significance of knowing my cultural identity history until I moved to Kamloops, BC, to pursue
my Master of Nursing degree. Since my arrival, I have engaged with not only people with
diverse racial, ethnic and cultural backgrounds, but also Indigenous people or First Nations, Inuit
and Métis who survived colonialism, residential schools and genocide in Canada. Moving from a
familiar environment into the unfamiliar filled a gap in my ancestral knowledge because I was so
accustomed to a single racial, ethnic, and cultural group. Since my arrival, I have determined to
learn about the culture, history and heritage in Canada while maintaining my cultural identity as I
transition to practice nursing in a multicultural society (acculturation) (Esegbona-Adeigbe,
2023).
Although I always believed that culture mattered when providing care to patients as a
Registered Nurse (RN), cultural competence was not part of the nursing curriculum or hospital
policy in The Bahamas. Nonetheless, I decided to consider the cultural background of patients

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when developing a care plan in the hospital and clinics. Out of all of my clinical rotations,
maternal health piqued my interest. My first day in the labour room was during alate shift.
Shortly after receiving the nursing report, I was faced with a young lady about to give birth to
her first child. While in labour, I stood by the bedside, held her hand and encouraged her to
breathe (slow, deep breaths in and out). When she gave birth to her baby, and I was about to walk
out of the room, she whispered, "Please stay". It was this moment that shifted my perspective on
a nursing career – it is not a job, but a calling to serve.
Another experience that strengthened my belief occurred while working on the postnatal
unit. A newborn with symptoms of yellow skin and eyes was diagnosed with jaundice. This
patient needed medical treatment; however, the new mother did not speak English. This was my
first encounter with a patient who did not speak or understand English, and the hospital did not
have a policy in place at that time. I did not know what to do, but I did not ignore or neglect the
patient. I spoke to the nurse in charge, and arrangements were made for the patient to talk with a
nurse who spoke the same language. The mother's face lit up while speaking with a nurse who
spoke their language. This moment was another shift in my perspective – culture is essential
when interacting with patients. As I conduct this study, my nursing philosophy is that I am who I
am because you are. I see every person as I see myself. This is one of my core values as a person,
a woman and a mother.
Before conducting this study, I reflected on my nursing philosophy as well as my core
values as a person, a woman and a mother. I must see every person as I see myself and treat them
accordingly. I adopted the word Ubuntu, a traditional South African philosophy, as one of my
core values. Ngomane (2020) said, “I am only because you are”. Therefore, when interacting
with someone whose values, beliefs, customs, and traditions differ from my own, I maintain my

23

cultural identity while considering others, as I now embrace cultural diversity. The opportunity
to conduct this study is not because I am privileged, but rather to serve culturally diverse patients
as an RN, to pursue and gain a deeper cultural understanding, and, most of all, to be willing to
take appropriate actions to provide culturally safe and inclusive healthcare.
I would like to acknowledge that I conducted this study in Secwepemcúl'ecw, in the
unceded territory of Tk̓emlúps te Secwépemc. During this study, I understood that
acknowledgment of the Indigenous People or First Nations, Inuit and Métis in Canada is my first
step toward truth and reconciliation and revitalization of their culturally distinct racial and ethnic
groups that were dismantled due to colonialism. Alexis Gottfriedson, Knowledge Holder,
kukwstsétsemc (thank you so much!) for taking the time out of your busy schedule to teach me
Secwepemctsín (Secwépemc language).
Chapter Summary
This chapter introduces the background and context of the study, outlining the problem
and guiding research questions, as well as the research purpose. The study aims to explore the
meaning of culture from the perspectives of RM in BC and to examine how this understanding is
applied in multicultural healthcare settings. Using the CCF, the research addresses four key
questions to investigate how cultural competence is understood and practiced in midwifery care.
The next chapter will review existing literature on cultural competence in midwifery, patient
experiences, and other relevant findings in the literature.

24

Chapter Two
Review of the Literature
A literature review was conducted to explore the concept of culture and cultural
competence in nursing and midwifery, encompassing cultural knowledge, skills, and resources
utilized to support the delivery of culturally congruent care. It also examined the cultural
influences on midwifery care and the cultural considerations in patient care within midwifery
practice. This literature review aimed to identify nursing knowledge from both quantitative and
qualitative research regarding cultural competence in midwifery care.
Search Strategy
Search Plan and Record
The initial search began with brainstorming keywords, terms, phrases and keyword
synonyms related to my research questions. A plan was written using the keywords, terms, and
phrases discovered during the initial search, and new terms were added and recorded to track
progress throughout the search (see Appendix J). A comprehensive search of the topic was
conducted using the EBSCO Discovery Service, located in the library at Thompson Rivers
University, Kamloops, British Columbia. The search engine served as a search tool to conduct a
comprehensive search across most of the library's databases, identify the database's standardized
subject terms, and become familiar with the standard database search features (Polit & Beck,
2021).
I typed the basic keywords into the search box: "cultural competence, midwives, British
Columbia and Canada". I engaged with a professional librarian and provided my initial search
plan for refinement. A revised search was recommended by the librarian (see Appendix J). I
accepted the librarian's recommendations as follows.
The search results comprised 7,367 observations that were scanned and then refined. A

25

chart was finalized to outline the databases searched, date of the search, search terms and
searching strategy, the number and types of articles found and an estimate of relevant articles
(Gray & Grove, 2021) (See Appendix J).
The inclusion criteria were set as follows: language (English only); years to be covered
(1901 to 2025); peer-reviewed articles and studies to include grey literature (academic scholarly
journals, government agency reports); dissertations (such as projects, theses and position papers);
and geography (Canada). The exclusion criteria were set as follows: language (non-English),
years to be covered (before 1901), and non-peer-reviewed sources (including periodicals,
newspapers, and magazines). The inclusion and exclusion criteria were in alignment with my
research questions for searching bibliographic databases.
Database Selection
Bibliographic databases were utilized to conduct literature research (Polit & Beck, 2021).
Searching databases is a convenient, efficient search strategy that can be used on electronic
devices, such as computers, tablets, and smartphones (Polit & Beck, 2021). Five (5) electronic
databases were selected: Cumulative Index to Nursing and Allied Health Literature (CINAHL),
Medical Literature On-Line (MEDLINE), PsycINFO, Academic Search Complete and Education
Resources Information Center (ERIC). PubMed and Google Scholar were also used as additional
tools. Seminal works, grey literature and government reports were retrieved from Government of
Canada websites such as Statistics Canada and Health Canada. Other library databases were
ProQuest and the Web of Science suite of databases.
Further, search strategies included citation tracking, handsearching and snowballing to
identify studies missed by database searching alone. Some articles that were not readily available
in the library were retrieved through the interlibrary loan option.

26

Search Strategies in Bibliographic Databases
As recommended by the librarian, two search methods were used for the bibliographic
databases. The first method was to search for standardized subject terms, and the second method
was to enter keywords and keyword synonyms into the search field to “yield overlapping but
nonidentical results” (Polit & Beck, 2021). Keywords were searched separately and then
combined with subject headings. To carry out this process, general database search features were
used as follows: truncation symbols, such as an asterisk (*).
Cultur* competence was used as the root term for cultural competence (cultur*
competence), and midwif* was used for midwives. Boolean operators “AND”, “OR” and “NOT”
were used to “expand” or “delimit” the search (Polit & Beck, 2021). The search I used was as
follows:
AB ("Cultural Competence" OR "Cultural Safety" OR "Cultural
sensitivity" OR "Cultural awareness" OR "Cultural humility" OR
"cultural awareness" OR "cultural congruency" OR "cultural
appropriat*" OR "Culturally congruent" OR "Cultural profic*" OR
"Cultural compassion" OR "Cultural empathy" OR Indigenous OR
aboriginal OR immigrant) AND ("Midwif*" OR "Maternal" OR
"Perinatal" OR "Antenatal" OR "postnatal" OR "postpartum" OR "birth"
OR "childbirth" OR "antepartum" OR pregnancy).
Further limits were applied in Canada over the last decade, resulting in a total of 347
articles retrieved, with duplicates removed, leaving 391 articles to review. One hundred seventyfive relevant articles were saved in a temporary folder and exported to the software Zotero. Titles
were screened first, followed by an examination of the abstracts. Relevant sources were

27

retrieved, and full-text articles for all citations were downloaded and saved in a folder on the
desktop of a computer for future review. Similarly, a recent search was conducted over the last
twelve months to identify any new literature (see Appendix J). Of the 95 articles reviewed, six
relevant articles were saved and included in the study.
An account was created in the library database to save the original search, and
arrangements were made to receive email notifications of new articles with updates related to the
topic (Gray & Grove, 2021). SCImago Journal & Country Rank is a publicly available portal that
includes scientific indicators for journals and countries, developed from information contained in
the Scopus database (Elsevier B.V.). These indicators allow for the comparison and analysis of
journals separately (SCImago, 2002). To evaluate the quality and accuracy of the peer-reviewed
journals, the SCImago database was used to identify journal rankings. Based on the analysis of
the literature, three themes emerged:

•

Cultural competence in healthcare,

•

Cultural competence in midwifery care, and

•

Patients' experiences in maternal health.

Theme 1. Cultural Competence in Healthcare
Historically, extensive empirical work has been conducted to substantiate the concept of
cultural competence in healthcare. In centuries past, the idea of cultural competence was closely
tied to cultural diversity until the 20th century (Zander, 2007). Cross et al. (1989), coined the
term cultural competence from the words ‘culture’ and ‘competence’. Culture referred to a
person's ethnicity, race or traditions and competence referred to the ability to carry out the work
efficiently (Cross et al., 1989, p. 13). Cross undertook the development of cultural competence
and formulated a system to optimize the delivery of mental health services by healthcare

28

professionals, institutions and organizations for culturally diverse children.
A study by the Institute of Medicine (2003) found that incorporating cultural needs into
the plan of care for culturally diverse patients improved the quality of care. The results from this
report spread rapidly worldwide among healthcare professionals and became one of the
foundational elements in establishing cultural competence in healthcare. Assessment and
integration of the cultural needs of culturally diverse populations ensures that culturally
congruent care is achieved. Among this empirical work, cultural competence has become highly
recognized in the field of nursing.
Leininger (1997), a renowned pioneer, emphasized that while care and culture are
invisible, both are vital in the field of nursing; hence developed the term culture care and the
Theory of Culture Care Diversity and Universality. Leininger held that care should be studied
systematically from a holistic cultural perspective to discover, improve, and provide culturally
congruent care that benefits the patient (Marriner-Tomey & Alligood, 2006). Moreover,
Leininger held that culture care encompasses the patient's cultural background and incorporating
their values, beliefs, customs, and traditions into the care goals (Leininger, 1997). Building on
Leininger's work in transcultural nursing, Lea (1994) explored the concept of culture in Canada.
She recommended that nurses in Canada consider the cultural differences of patients to provide
effective nursing care. This article piqued my interest in my literature search because it was one
of the first nursing research papers found that was related to culture and conducted in British
Columbia, Canada during the 20th century while the terms culture and cultural competence were
evolving (Canales & Bowers, 2001; Jirwe et al., 2006; Kim-Godwin et al., 2001; Marcinkiw,
2003; Purnell, 2000; Purnell, 2001; Suh, 2004).
Similarly, Capell et al. (2008) conducted a quantitative study in Vancouver, British

29

Columbia, to examine the connection between cultural competence and ethnocentrism.
Ethnocentrism is an established term referring to the perception that one's worldview is superior
to others (Capell et al., 2008). Ethnocentrism inhibited culturally congruent care (Capell et al.,
2008). A sample of 71 culturally diverse healthcare professionals, consisting of physical
therapists, occupational therapists, and nurses, completed a 25-item questionnaire. It was
determined that there was no distinction between cultural competence and ethnocentrism, and
further research was recommended to measure the impact on patient health outcomes and patient
feedback, as well as to implement training. The adoption of cultural competence in Canadian
healthcare has added to the body of nursing knowledge; however, the meaning of cultural
competence in nursing remains broad and complex, lacking a conclusive, universal definition.
During the same period, other scholars contributed to the development of cultural competence
through interventions and models of care aimed at improving healthcare delivery.
Schim et al. (2007) presented two models to achieve culturally congruent care for use in
various healthcare disciplines, focusing on culture, culturally congruent care, cultural diversity,
cultural awareness, cultural sensitivity, and cultural competence. The models were utilized in
educational environments as a framework, and further testing and research were recommended to
refine and develop the models. While Schim et al. (2007) focused on patient care, the Registered
Nurses' Association of Ontario (2007) developed a Best Practice Guideline with a focus on
cultural competence in the work environment for nurses. Since then, limited studies have been
conducted regarding interventions or models of care for cultural competence. While cultural
competence has evolved and had an impact in the last two decades, the concept has
metamorphosed into cultural safety over the past fifteen years, especially in the context of
Canada (Hart-Wasekeesikaw, 2009; Stamp et al., 2008).

30

Vandenberg (2010) identified issues related to building the theory of culture in nursing,
noting that providing interventions alone was insufficient. For this reason, Vandenberg (2010)
recommended that nursing researchers should consider the historical, political and economic
factors related to health, recognize the emergence of the concept cultural safety, investigate the
perceptions of patients as it relates to cultural preferences and most importantly, continue the
work of conceptualizing the impact of culture on health and practice. To advance the
development of cultural competence, Soulé (2014) conducted a qualitative study with a sample
of 20 experts in the fields of nursing, medicine, and social work. Three themes were identified:
awareness, engagement, and application within three domains—intrapersonal, interpersonal, and
system or organizational. Although this study reintroduced cultural competence to the literature,
it is essential to note that empirical work in Canada on cultural competence in healthcare over the
last ten years is meagre.
Researchers found that there were limited strategies to improve cultural competency for
Indigenous peoples (Clifford et al., 2015; Rissel et al., 2023). Even so, this concept was still not
clearly defined. Darroch et al. (2017) found that the term was used more readily in the context of
Canada than in the United States of America (USA). They recommended that researchers from
the USA adopt the term “cultural safety”. Curtis et al. (2019) suggested that the definition of
cultural safety be adopted by healthcare organizations in New Zealand and globally to achieve
health equity for the Indigenous population.
According to Curtis et al. (2019), cultural safety refers to health care providers, along
with their employers, who were responsible for determining the influence of their own culture
when providing care and acknowledging and addressing personal judgments that may interfere
with care delivery. In addition, Greenwood et al. (2017) recommended that non- Indigenous

31

healthcare professionals, systems and organizations adopt Indigenous ways of knowing and
being when delivering health services to the Indigenous population. For example, topics related
to maternal health were translated into fact sheets, reports, and webinars. Given these points,
cultural competence and cultural safety differ in origin and definition; however, their application
is the same. Notably, the primary focus of cultural safety is applied when care is provided to the
Indigenous population (Srivastava, 2023).
Henceforth, many researchers have contributed to defining the concept of cultural
competence (Abualhaija, 2021; Blanchet Garneau & Pepin, 2015). Cultural competence and
cultural safety differ in the definition and origin but the application of both are the same noting
that the focus of cultural safety is applied when care is provided to the Indigenous population
(Srivastava, 2023, p. 18). Moreover, researchers have conducted studies from 2002 to 2016 that
outlined strategies to improve cultural competence in healthcare organizations in New Zealand,
Canada, the USA, and Australia at both the individual and organizational levels (Handtke et al.,
2019; Jongen et al., 2018; McCalman et al., 2017). While this concept is notable in the
healthcare field today, its meaning remains broad and complex, lacking a conclusive universal
definition.
For this study, cultural competence will be defined by participants in their own words,
expressing their perspectives using their vocabulary and rephrasing the meaning according to
their level of understanding, without assistance from quoting another person or source of
information (e.g., textbook, Google search engine, social media).
Theme 2. The emergence of Cultural Competence in Midwifery Care
The term cultural competence varies according to the context. In midwifery, the term
cultural safety was introduced historically, but chronologically, there is inconsistency in the

32

literature - for example, the term cultural safety was used in midwifery in New Zealand, but the
term cultural competence was used in midwifery in Canada or USA. Historically, in 1992, the
concept of cultural safety became a mandatory course requirement in the nursing curricula for
nursing and midwifery programs in New Zealand (Papps & Ramsden, 1996). However, there is
limited evaluation of how introducing cultural safety into nursing and midwifery programs works
in real-life settings to improve the health outcomes of the Māori population (Johnstone &
Kanitsaki, 2007; Richardson, 2004).
Surprisingly, to say the least, Thackrah et al. (2020) reported in a study of 14 midwifery
students and recent graduates that incorporating cultural safety courses in the curriculum
improved the knowledge and clinical practice of the participants. Briscoe (2013) also identified
other improvements in practice, such as better engagement with culturally diverse patients,
greater self-awareness of cultural differences, and more profound reflections that contributed to
professional growth. Therefore, the delivery of cultural competence needs to be demonstrated in
practice.
Incorporating cultural competence into midwifery practice is challenging, especially
when the necessary knowledge, skills, and resources are not explicitly demonstrated in higher
education programs and clinical practice. Marriott et al. (2020) reported that in a study of 61
clinical midwives, they were unable to define cultural safety, even alternative concepts such as
cultural security or cultural competence, as common responses from participants were “nothing”.
Moreover, birthing traditions were not part of routine clinical practice and were even considered
“optional” (Marriott et al., 2020; Pirhofer et al., 2022). Not to mention the heightened anxiety of
patients due to the lack of training of midwives to meet cultural needs (Tobin et al., 2014). Most
importantly, Marriott et al. (2020) identified healthcare system problems resulting from the lack

33

of support at the organizational level, as well as the significant shortage of midwives.
The delivery of cultural competence in midwifery practice should incorporate the cultural
preferences of culturally diverse populations. Several studies have elucidated the delivery of
cultural competence in midwifery care in Canada (Burton & Ariss, 2014; Cioffi, 2004; Hanson et
al., 2013; Thiessen et al., 2020). Indeed, Burton and Ariss (2014) reported in a study of 16
midwives that understanding cultural diversity was part of their duty in a diverse society, such as
Ontario, and they were able to articulate the meaning of cultural competence in midwifery
practice clearly. In addition, despite pushback in a biomedical system, participants were
committed to supporting the cultural preferences of culturally diverse pregnant patients (Burton
& Ariss, 2014).
While Hanson et al. (2024) explored documents of policy and protocol of professional
nursing and regulatory organizations and interviewed key informants (total number not provided)
across five provinces such as British Columbia, Manitoba, Ontario, Northwest Territories, and
Nova Scotia as it relates to the quality of and access to midwifery care, quality and access refer
to services, supplies, and resources, including funding, treatments, the workforce, and other
essential services (Hanson et al., 2024). Similarly, Thiessen et al. (2020) reported that Manitoba
experienced shortages of midwives and limited funding. Yet, midwives were essential in
providing maternal health services, particularly during the nine years marked by a 35% high birth
risk. Midwives reduced the rate of cesarean procedures and other invasive procedures (surgical
cuts), and even increased breastfeeding postpartum (Thiessen et al., 2020).
Equally important, Cassidy (2024) recognized that there is a relationship between culture,
cultural competence, cultural safety, and breastfeeding, such that incorporating cultural
preferences into care results in a better understanding of cultural differences, while developing

34

rapport, holistic support, and openness to breastfeeding postpartum. With evolving healthcare
interventions, the ongoing growth in diverse populations along with many demands for culturally
competent care in midwifery, it is not surprising that midwives are constantly faced with the
challenge of meeting cultural needs on a day-to-day basis (Alzghoul et al., 2021; Corcoran et al.,
2017; Handtke et al., 2019; Higginbottom et al., 2013b; Khanlou et al., 2017; Machado et al.,
2022; Marriott et al., 2019; Perera et al., 2023; Winn et al., 2018).
To date, the terms “culture”, “cultural competence”, “cultural safety”, and “cultural
humility” are prevalent in government, professional nursing, and regulatory organizations, as
well as on social media platforms such as Facebook, Instagram, Twitter, LinkedIn, and YouTube
and the meanings may vary based on the context. Ultimately, raising awareness through
technology should enhance the capacity to build "equitable healthcare" (Curtis et al., 2019;
Williamson & Harrison, 2010). Yet, several studies have found that the term ‘culture’ in nursing
and midwifery care is ambiguous (Capper et al., 2023; Marriott et al., 2019; Williamson &
Harrison, 2009).
To understand the concept of culture, two approaches can be taken. The first approach is
the cognitive approach, which concentrates on the “values, beliefs and traditions” of diverse ethnic
groups (Williamson & Harrison, 2010). The first approach involves the explicit or implicit
characteristics of culture, such as customs, traditions, language, values, beliefs or geographical
location (Williamson & Harrison, 2010). In contrast, the second approach is taken from a broad
vantage point and focuses on a person's “social position” (Williamson & Harrison, 2010, p. 762).
The second approach involves viewing culture from another standpoint, for example, considering
the health status of a culturally diverse person, rather than the first approach mentioned earlier.
The second approach involves considering any historical events that may have impacted the

35

patient's health (Williamson & Harrison, 2010).
However, both approaches fail to address racism and discrimination. Interestingly, there
appears to be good evidence that racism is becoming a recognized phenomenon in nursing, often
hidden within structural institutions and nursing policies (Kimani, 2023; Machado et al., 2022;
Vaismoradi et al., 2022; Vang et al., 2018).
Theme 3. Patient Experiences in Maternal Health
Several qualitative studies have found that cross-cultural interactions and the quality of
care in maternity health settings are poor (Akter et al., 2020; Bacciaglia et al., 2023; Dube et al.,
2024; Kolahdooz et al., 2016; Nielssen et al., 2024; Tobin et al., 2014; Vang et al., 2018). Vang
et al. (2018) reported in a study of 25 Inuit and First Nations women during the antepartum and
postpartum periods, as well as eight physicians and nurses, that non- Indigenous healthcare
providers judged patients based on how they responded to questions. For example, a nurse stated
that Indigenous patients give "short and simple answers". This was a pet peeve for the nurse,
who, in translating it into care, resulted in judgments, and as a consequence, the patient was
misdiagnosed as being "non-compliant, uneducated or rude" (Eckler et al., 2023; Gleason et al.,
2022; Vang et al., 2018).
Importantly, Higginbottom et al. (2015) found in a study of 31 participants (12 immigrant
women, 13 healthcare providers, and six social service providers) that even when treatment is
explained in the patients' mother tongue, medical terminology can result in misunderstandings.
For example, "Nurse ask me, 'You know about that HVP test?' So, I said, 'I don't know.' She said
to me, 'You suggest yes or no?' So, I said no because I can't understand so that's why I said "no".
HPV is the acronym for human papillomavirus, a sexually transmitted infection that can cause
significant complications during pregnancy; therefore, it is a routine test. In this case, the test

36

was not explained in simple, easy-to- understand language, so the participant could not feel
confident in their response to the question.
Anxiety was elevated during the perinatal period, particularly for Indigenous women
living on reserved land due to birth evacuation (Abdullah et al., 2017; Kolahdooz et al., 2016;
O'Driscoll et al., 2011; Perera et al., 2023; Vang et al., 2018). Birth evacuation is an invisible
mandate by the government for pregnant women to leave their homes weeks before childbirth,
especially if their condition is diagnosed as high risk (Corcoran et al., 2017; D'Souza & Leslie,
2023). Heightened emotions of loneliness, isolation, and feelings of depression. For example,
one patient stated that "I went through the depression badly, because I had to be in Vancouver so
long by myself. I didn't know anyone" (Corcoran et al., 2017; Kolahdooz et al., 2017; O'Driscoll
et al., 2011; Vang et al., 2018). In the same manner, Chopel (2014) reported in a study including
31 government agents and Indigenous community leaders that women did not seek medical care
due to the fear of leaving their homes, animals and families behind childbirth. Instead, women
preferred to give birth in their homes without a healthcare provider or near their home, instead of
taking the risk on the unpaved roads from their community to the hospital.
To alleviate anxiety, O'Driscoll et al. (2011) recommended that a doula (unlicensed
healthcare worker) should be present to provide emotional support during pregnancy (Healthwise
Staff, 2022). In contrast, Pimienta et al. (2023) found that culturally diverse pregnant individuals
new to Canada lacked social support during the perinatal period because they were no longer
with their close relatives in their home country, who would usually have provided support.
Healthcare providers should consider these emotional triggers when giving care to alleviate
anxiety (Wright et al., 2019).
Lack of trust is a common issue in the healthcare system. One reason is due to the fear of

37

losing one's baby after childbirth. Higginbottom et al. (2015) reported that a social worker
experienced a situation in which the patient was waiting for the nurse to touch the baby while the
nurse interpreted this behaviour as "abandoning her baby". Similarly, Higginbottom et al. (2016)
conducted a study with 86 participants (34 immigrant women, 29 healthcare providers and 23
social workers). They found that trust was lacking due to the "cold" attitude from healthcare
providers, particularly during clinical visits. Without trust during patient interaction, is there an
actual exchange of information?
Power dynamics during care disrupted the sense of respect and security. Niles reported in
a study of 2,900 childbearing women in BC their experiences during care. Power was translated
based on the provider's knowledge, which belittled or disregarded the knowledge shared by the
patient. This interaction left the participant feeling disempowered, to the point of secondguessing their understanding. This is demonstrated by the exemplar below:
I did a lot of research before my daughter's birth to understand what I could and
could not refuse, while still keeping my daughter and me safe. [They] denied
delayed cord clamping, skin-to-skin contact and my husband cutting the cord.
After my daughter's birth, I refused the oxytocin shot, knowing that my body
would produce its own given the chance to nurse my baby. I declined the
routine IV fluids and asked to drink water to rehydrate myself, and I asked not
to have stitches. At the same time, I was given a shot of oxytocin, stitches and
an IV. They treated me like I knew nothing. I felt like a third-class citizen,
disrespected, stupid and very scared, realizing that I had absolutely no say in
what they were going to do to me (Niles et al., 2021).
Also, a mother in labour was feeling weary and wanted to rest. Still, midwives kept

38

insisting that she should get oxytocin (a drug used to increase the contractions of the uterus) to
speed up delivery (Niles et al., 2021). Feeling frustrated by their demands, the mother gave in to
the bullying and suffers from recurring nightmares long after the experience (Niles et al., 2021).
Tobin et al. (2014) found that women seeking asylum in Ireland experienced no
connection with the perinatal provider due to a disorganized maternity setting, lack of cultural
training and interpreter services, which resulted in overwhelming feelings of abandonment.
Similarly, immigrants experienced barriers in maternity care from perinatal providers,
which included isolation, stigma related to mental illness in pregnancy, racial judgements,
indifference and privacy and consent violations (Alzghoul et al., 2020; Higginbottom et al.,
2014; Higginbottom et al., 2015; Pimienta et al., 2023). Moreover, immigrants were separated
from their family members, friends and the community and experienced breach in confidential
information and wrong assumptions from perinatal providers from the same culture
(Higginbottom et al., 2015; Machado et al., 2022). Not to mention, Perera et al. (2023) reported
in a study of nine women that stigmatization, lack of access, funds and inability to commute for
mental health services escalated during the COVID-19 pandemic for women during the perinatal
period.
Notable Findings: Racism and discrimination
As mentioned earlier, findings thus far suggest that racism is highly prevalent in nursing.
Current studies have shown that culturally diverse patients in Canada experience culturally
unsafe care, including racism, discrimination, and prejudice (Hart- Wasekeesikaw, 2009;
Marriott et al., 2019; Minister of Health, 2018; Pimienta et al., 2023). For ethnic minorities,
nurses demonstrated implicit bias and racist attitudes towards them, coupled with a lack of
support and compassion (Boakye et al., 2023; Odems et al., 2024; Olukotun et al., 2024; Aerts et

39

al., 2024).
Boakye et al. (2023) reported in a study of 24 Black pregnant women in Toronto that in
maternal health settings, Black women were ignored during labour, received no form of
communication from the health care provider when the provider entered the participant’s room,
and they experienced inhumane treatment; for example, no one introduced themselves, provided
any eye contact, no respect to the participant’s body even the newborn after childbirth. This
finding aligns with Markey (2020), who noted that nurses were culturally insensitive, less
engaged, and indifferent toward culturally diverse patients. Moreover, Markey (2020)
emphasized that nurses should wear a moral lens to examine their intentions, behaviours, actions
and decisions in nursing education and practice. In the final analysis, these findings highlight the
unexplored areas of research that remain to be investigated in the development of cultural
competence in midwifery care.
Theoretical and Epistemological Frameworks
Leininger (1995) predicted that in the year 2020, transcultural nursing would be
beneficial in nursing education and practice, and unbeknownst to the world, the Coronavirus
disease (COVID-19) pandemic exaggerated the need for skills in understanding cultural diversity
and providing culturally congruent care (p. 687). In light of this, the Culture Care Framework
(CCF), developed by Srivastava in 1996, was identified as the most appropriate lens through
which to view this study (Srivastava, 2023). The CCF aims to simplify the concept of culture,
providing a strategy for healthcare professionals to approach the influence of culture on health
and healthcare, thereby facilitating the development of cultural competence (Srivastava, 2023).
Embedded in the CCF are core concepts from Leininger’s (1997) Theory of Culture Care
Diversity and Universality.

40

The Theory of Culture Care Diversity and Universality focuses on culture and care,
employing three action decision modes to translate culture into care, resulting in culturally
congruent care (McFarland & Wehbe-Alamah, 2019; Marriner-Tomey & Alligood, 2006). The
universality of care reveals the common nature of human beings and humanity, while diversity of
care shows the variability and selected, unique features of human beings (McFarland & WehbeAlamah, 2019; Marriner-Tomey & Alligood, 2006). The CCF was identified as the most
appropriate lens through which to view this study, as RMs in BC provide care to culturally
diverse patients and families daily in multicultural healthcare environments. The CCF is
composed of three key elements, which include Cultural Sensitivity, Cultural Knowledge, and
Cultural Resources, followed by three modes of decisions and actions that healthcare
professionals can use to integrate cultural knowledge and values into practice (Srivastava, 2023).
A schema of the CCF was constructed with three circles interlocking one another (See
Figure 1). These three key elements, when combined, become a prerequisite for actions and
decisions to be realized in the process of cultural competence. As a stand-alone, each circle
representation is holistic but insufficient, because together they generate key values and beliefs
for cultural competence that unlock the modes of action and decision-making that result in
culturally congruent care (Srivastava & Mawhinney, 2023).
Cultural Sensitivity
Cultural Sensitivity refers to having an awareness of self, understanding one’s own
cultural identity, values and beliefs, as well as understanding the culture of others without
judgment (Srivastava, 2023). This awareness is a process that may involve self-reflection,
understanding how others perceive you, and identifying other cultural differences. Srivastava
(2023) emphasized that healthcare professionals must evaluate the way they view age, gender,

41

ethnicity, or the religion of others during patient interactions, as well as the impact of historical
origins, the level of trust, equity, and power given and reciprocated in those interactions.
According to the CCF, Cultural Sensitivity is composed of cultural awareness. The
cultural awareness of healthcare professionals is critical to understand because cultural identities
have a significant impact on human interaction, to the point where the cultural identity of another
can either be strengthened or silenced (D’Souza & Leslie, 2023; Srivastava, 2023). According to
Srivastava (2023), Cultural Sensitivity refers to a healthcare professional who understands their
own culture and cultural identity. Srivastava claimed that there are shared identities within a
cultural group that are self-imposed, imposed by others or passed down historically. These
identities can either strengthen or silence the cultural identity of another during human
interaction; therefore, healthcare providers must be aware of and understand their own cultural
identity (Srivastava, 2023).
Cultural Knowledge
Cultural Knowledge refers to the worldviews that health care professionals perceive and
believe about various cultural groups, which is conveyed appropriately or misapplied when
providing care (Srivastava, 2023). This two-part (generic and specific) knowledge may include
but is not limited to familiarization with health, illnesses, health inequalities, issues related to the
exchange of information during patient interaction and the efforts to obtain this knowledge
(Srivastava, 2023). Srivastava (2023) stressed that this knowledge is established when healthcare
professionals recognize that their acquired knowledge, networking with others, and access to
resources are not superior or even comparable when providing care.
Cultural Knowledge is a key element of the CCF and is necessary for cultural
competence in health care. This element refers to the worldviews that healthcare professionals

42

perceive and believe about various cultural groups, and this knowledge is used appropriately
when providing care (Srivastava, 2023). Generic knowledge and specific cultural knowledge are
two subcomponents of Cultural Knowledge that relate to understanding the cultural patterns of
cultural groups, using them when applicable, and identifying cultural issues within these groups,
such as mental health care, home birth, or hospital care.
Cultural Resources
Cultural Resources refer to training, skills, resources and tools that are readily available
for the process of cultural competence. These resources encompass three- dimensional levels
(individual, organizational, and professional/social) that are essential for healthcare professionals
to be well-informed in a comprehensive manner (Srivastava, 2023). Srivastava outlined ways in
which learning can occur, which involve pursuing cultural information, evaluating past
experiences, and establishing a variety of networks through personal efforts, on-the-job training,
or within the community.
Cultural Resources include sources of information that can be accessed by healthcare
professionals at the individual, organizational, professional, and social/community levels
(Srivastava, 2023). Resources are not bound to text and technology; however, having a desire to
have an environment where people learn from each other is significant when developing cultural
competence (Srivastava, 2023).
Cultural Care Action and Decision Modes
To meet the goal of culturally congruent care, Srivastava (2023) envisioned action and
decision modes. The three modes are considered and determined by the action taken by
healthcare professionals in conjunction with the patient, according to the following components:
1.

Cultural Care Validation/Preservation – recognition of core

43

values and beliefs that are supported in a respectful manner.
2.

Cultural Care Accommodation/Negotiation – ongoing
engagement to mutually agree on care preferences.

3.

Cultural Care Reframing/Repatterning – conversations
about new and/or different options of care.

Srivastava recognized that this was the platform upon which cultural competence is
demonstrated and incorporated by healthcare professionals (Srivastava, 2023).
Figure 1
Culture Care Framework

Note: From “The Healthcare Professional’s Guide to Cultural Competence,” by Srivastava, R. H.,
2023, p. 55. Copyright 2023 by Elsevier Inc. (copy with permission from the author).

44

Assumptions of the CCF
Adopted from Theory of Culture Care Diversity and Universality and the CCF, it is
assumed in this study that:
1. Midwives in BC with adequate experience providing care of culturally
diverse patients will participate in this study and express their
perception of cultural competence in midwifery care.
2. This study involving midwives and using the CCF as a theoretical
framework is appropriate and suitable for research.
3. Culture care values, beliefs, and practices of midwives are influenced
by worldview and social factors such as religion, spirituality,
environment, and politics.
4. Midwives have their own knowledge and values of health care and
work with the knowledge and values of culturally diverse patients.
Overall, the CCF highlights that cultural competence is a broad and complex concept
essential to delivering quality care. Exploring how RMs in BC understand and apply cultural
competence in caring for diverse populations can enrich nursing knowledge and clarify how this
concept is integrated into midwifery practice.
In this study, I used two theoretical approaches for my qualitative research design. My
theoretical approach was grounded in the CCF, identified in chapter one as one of the appropriate
lenses through which to view this study. A key assumption arising from the CCF that I adopted
from Madeleine Leininger’s (1997) Theory of Culture Care Diversity and Universality is that the
qualitative paradigm explicates in various ways to unveil new knowledge and realities of the
multidimensional aspects of caring for human beings (Petiprin, 2025). The epistemological and

45

ontological approaches were informed by Carspecken’s (1996) Critical Theory. Positivist
epistemology does not address the most crucial question, “why?”.
Carspecken (1996) claimed that any agreement on a truth claim by a cultural group can
be accepted in one historical period and rejected in another, which makes it susceptible to error.
Critical Theory research focuses on, but is not limited to, understanding culture, power, and the
mechanisms of oppression in a society (LoBiondo-Wood et al., 2018; Polit & Beck, 2021).
Critical epistemology and ontology involve the comprehension of the relationship between three
main categories: 1) power, thoughts or ideas, culture and truth claims, 2) the connection between
facts and values, and 3) symbolic representation of a theory (Carspecken,1996).
Carspecken’s (1996) stages four and five of critical qualitative research were identified as
the other strategic approach used in this study. Stages four and five were appropriate for this
study, which conducted interviews only, while stages one through three refer to studies that
involve prolonged engagements and on-site observations, for example, an ethnographic study. In
stage four, the historical, political, economic, environmental, and social contexts are considered
to analyze the relationships between the social site and the cultural group. For this study, the
social site for the RMs in BC was the Canadian healthcare system in BC. Stage five involves
taking the analysis from stage four and combining it with the findings in the data to a higher level
of analysis, presenting strategies for resolution given the macro sociological theory identified. In
this study, the macro sociological theory identified is health equity, which is the ideal goal in
healthcare and the link to the conditions outlined in stage four. This approach was adopted due to
the discovery of a mismatch between the CCF and the data findings, which will be addressed in
the Discussion section (chapter five).

46

Chapter Summary
The literature review identified research articles, books, and other materials that informed
this study. Three main themes were presented from the review of the literature: 1) Cultural
competence in healthcare, 2) Cultural competence in midwifery care and 3) Patient experiences
in maternal health, followed by Notable Findings: Racism and discrimination. The first theme
explored the meaning and evolution of culture, as well as cultural competence and cultural safety
in healthcare. It also includes racism, which is a human devaluing system, that is identified in
nursing. Addressing this issue is beyond the scope of this study; however, it demonstrates a lack
of cultural competence and serves as a prime example of how generalizations about a person’s
culture, whether in thoughts, feelings, or emotions, can lead to health inequities and exclusion.
The second theme examined the transition of cultural competence into midwifery
practice. The third theme identified patient experiences in culturally diverse environments and
their health outcomes. A final section was not anticipated but emerged from the literature.
The literature review indicated that culture matters in providing quality care and that there
is an urgent call for cultural competence to be implemented by healthcare professionals and
established within the healthcare system. Otherwise, culturally diverse patients will continue to
experience poor quality care and adverse health outcomes. The theoretical and epistemological
frameworks were presented to provide an overview of the frameworks that guided this study,
which included Srivastava’s CCF (2023) and Carspecken’s (1996) stages four and five of critical
qualitative research. Finally, the core concepts of the CCF informed by Leininger’s (1997) Theory
of Culture Care Diversity and Universality were outlined.

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Chapter Three
Methodology
The previous chapter described an overview of existing literature about cultural
competence in healthcare and midwifery, patient experiences in maternal health, followed by
notable findings associated with cultural competence in healthcare. Based on the review of
relevant literature, the following research questions have been explored:
1.

How do registered midwives (RMs) in British Columbia (BC) describe
culture in midwifery practice?

2.

What cultural knowledge, skills and resources do RMs in BC utilize to
support the delivery of culturally congruent care in midwifery practice?

3.

What are the cultural influences on midwifery care that inhibit or
support the delivery of culturally congruent care?

4.

How do RMs in BC integrate cultural considerations of care in practice?

Guided by the Journal Article Reporting Standards for Qualitative Research Design
(JARS-Qual), this chapter provides a thorough outline of the overall theoretical and
epistemological frameworks used in this qualitative inquiry. In addition, the qualitative research
design, including its rationale, ethical considerations, participant selection and recruitment, data
collection and recording methods, and data analysis strategies, is described to provide context
and facilitate a deeper understanding of the research work conducted in this study (Levitt, 2018;
APA, 2020). Finally, the methodological integrity of the study is addressed.
Research Design Overview
An explorative-descriptive qualitative research design is based on the learning theory and
pragmatism. Sandelowski (2000) alludes to some research, such as descriptive qualitative studies

EXLPORING CULTURAL COMPETENCE OF REGISTERED MIDWIVES

48

having “narrative,phenomenological, and ethnographic overtones” (p. 337). In other words, a
qualitative study may have the look or sound of these aspects which may occur by happenstance.
For example, a researcher may employ from constant comparison from the grounded theory
approach, but do not produce a theory (Sandelowski, 2000).
Pragmatism is a broad philosophical perspective that supports the methodology of
exploratory-descriptive qualitative research and is a worldview adopted by the researcher who is
“seeking to find a solution to a problem” (Gray & Grove, 2021, p. 250). As Mayumi and Ota
(2023) noted that well-known pragmatists such as Charles Pierce, William James, Richard Rorty
and Susan Haack established the term, pragmatism is not limited to a single specific
philosophical perspective and is “fitting” for discussions in nursing research (p. 9). Additionally,
Gray and Grove (2021) emphasized that in nursing, the primary goal of pragmatism is to provide
a knowledge-based solution to a problem that yields satisfaction and positive health outcomes for
patients, families, and communities. In this study, the overall purpose is to explore the meaning
of culture from the perspectives of RMs in BC and to explore ways in which this knowledge is
translated into midwifery practice for culturally diverse patients.
The main characteristics of exploratory-descriptive qualitative research are the freedom
to select a methodology that upholds the perspectives of participants, recognizing the problem or
issue, and providing solutions. Most importantly, the methodology aims to answer the research
questions (Gray & Grove, 2021). This explorative-descriptive qualitative research design was
deemed appropriate to explore the perceptions of RMs in BC with openness and to gain insight
into the impact of culture on midwifery care of culturally diverse patients (Gray & Grove, 2021).
To answer the four research questions, a Semi-Structured Open Inquiry Interview Guide
(interview guide) was developed and used with eight RMs in BC (see Appendix I). The guide

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49

included eight open-ended questions, along with probing questions, to create a relaxing
atmosphere for the interviews (Appendix I). One-on-one interviews were held using the TRU
Microsoft Teams platform.
Probing questions were included to encourage more specific responses to gather rich data.
Each RM was informed that there were no right or wrong answers, and they were encouraged to
share from their standpoint. This approach created a sense of freedom for participants to share
their perspectives and experiences in a focused yet non-confrontational manner. Interviews lasted
approximately 60 minutes to establish rapport and facilitate a free- flowing conversation (Polit &
Beck, 2021).
Study Participants
Recruitment Process
To recruit RMs, I developed a database from the online directory of the Midwifery
Association of British Columbia (MABC), which included the location and contact information
for RMs in BC. Six to eight RMs were determined as the appropriate number to provide
sufficient data to draw out the categories and themes, make the necessary conclusions, and
reassure me that collecting any further data would not produce any additional value-added
insights. RMs in BC were considered “key informants” due to their specialized knowledge and
experience in midwifery practice, as they provided care to culturally diverse patients daily (Polit
& Beck, 2021).
Participation in this study was strictly voluntary for one-to-one interviews. After
receiving REB approvals, I prepared a recruitment packet that included a poster and an
introductory letter addressed to midwifery organizations and RMs in BC. The letters included an
introduction with my full name, major, and degree, as well as the purpose of this study, an

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50

explanation of why I was conducting the study, the target population, and my phone number and
university email for direct contact. The letter addressed to midwifery organizations (see
Appendix E) included a request to share the letter addressed to RMs (see Appendix F) and the
poster on their communication platforms.
The recruitment packet was distributed via electronic and regular mail. I also contacted
midwifery organizations by phone if an email address was not listed or when I received
undelivered mail to confirm their preferred contact. For Royal Inland Hospital (RIH), my letter
and poster were placed in the Labour and Delivery department, which was most frequented by
RMs. The same advertisement was posted in two local Facebook community groups. When
interest in this study slowed during the recruitment process, I utilized the social media platform,
Facebook, and the TRU Campus Radio station, which was broadcast on the FM radio station.
Out of the 140 organizations, a total of 13 RMs expressed interest in this study. One RM
withdrew due to the loss of a family member. All signed documents received from this key
informant were permanently discarded at that point. After two weeks into the recruitment
process, four RMs did not indicate further interest. RMs who were interested in participating in
this study contacted me directly via my university email. Within a 48-hour timeline, I
acknowledged receipt of their email and included my available time for scheduling a meeting.
Participant Selection
RMs in BC were recruited using purposive and snowball sampling. Inclusion criteria were
midwives registered in the province of British Columbia; 18 years and older; able to read, speak
and understand the English language and having a minimum of one year’s experience in
midwifery practice. Exclusion criteria were doulas who were not RMs in BC. As previously
mentioned, the sample size of eight RMs in BC was deemed sufficient to achieve data saturation.

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51

Each participant provided in-depth, high-quality information, including explicit examples
of their perspectives, experiences, and strategies used to care for culturally diverse patients,
given their years of experience working with a diverse clientele (see Table 2). How interviews
were conducted will be discussed in the next section, but it is essential to note that one of the
factors contributing to the quality of the information received by participants was the way
rapport was established from the start of the interview, which is crucial for maintaining a
conversational flow. A total of eight RMs agreed to have the interview audio recorded. Three
RMs wanted to review the transcribed copy of the interview, while five RMs did not wish to
review it. I sent a copy of the transcribed interview to three RMs to affirm, clarify or edit their
responses within 10 days. Two RMs affirmed their copy, and one RM edited and returned their
reactions within the 10-day period.
Ethical Considerations and Procedures for Protection of Human Subjects
Research Ethics Board (REB) approval was obtained from TRU (see Appendix A). For the
local hospital in the city of Kamloops, RIH, Ethical approval (see Appendix B) and Institutional
approval (see Appendix C) were obtained from Interior Health.
Risk/Benefit Assessments. The level of risk or harm to RMs in this study was minimal
in terms of physical, psychological/emotional, social, or employment aspects. While the
interview questions were not intrusive, I verbally informed each RM at the beginning of each
interview session that they were free to interrupt me if they felt upset, distressed, or
uncomfortable while reflecting on specific experiences, and that I would stop the interview
session immediately. Each RM was informed that, if needed, support was readily available via
phone or text from the Canadian Mental Health Association’s Mental Health Crisis Helpline for
emotional support, mental health information, and resources (Canadian Mental Health

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52

Association, 2025).
There was no reported discomfort or perceived degree of coercion among any of the RMs
interviewed. It was communicated in the introductory letters that the information provided could
add to the nursing knowledge of what cultural competence in midwifery care means and how it is
integrated into midwifery practice. Additionally, no monetary compensation was offered to
participants.
Informed Consent Form and Demographic Profile. Full disclosure of the study
purpose and procedures was explained verbally at the beginning of each interview session and in
writing. RMs who were interested in participating in this study contacted me directly via my
university email. Within a 48-hour timeframe, I acknowledged receipt of their email and included
my available meeting times. Each RM was asked to respond to a series of demographic questions
(e.g. age, ethnicity) in the Demographic Profile for description purposes only. I emailed a total of
eight Informed Consent Forms (see Appendix G) and Demographic Profiles (see Appendix H)
that have been read, signed and returned to me via email by each RM.
It was communicated in the Informed Consent Form and verbally at the beginning and at
the end of the one-to-one interviews that participants had the right to withdraw from the study at
any point without any negative consequences. It was communicated in the Informed Consent
Form that all data from participants who request withdrawal will be removed from electronic and
paper files, deleted, and destroyed up to the point of data analysis. It was also stated that removal
of data after this point would not be possible. Out of the eight RMs, no one requested to
withdraw from the study.
RMs in BC indicated on the Informed Consent Form that they wished to have the
interview audio-recorded and to either deny or accept a transcribed copy of the interview for

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53

review. Eight RMs agreed to have the interview audio-recorded, three RMs wanted to review the
transcribed copy of the interview, and five RMs did not wish to review the transcribed copy. I
sent a copy of the transcribed interview to three RMs to affirm, clarify or edit their responses
within 10 days. Two RMs affirmed their copy, and one RM edited and returned their reactions
within the 10-day period.
Confidentiality and Anonymity Procedures. For anonymity, I developed a list of 10
random, three-digit Unique Identification Numbers (UID) for each participant to select from. To
prevent duplication, I immediately deleted the selected UID from the primary list before
distributing it to another participant. This list was sent to the participant via email along with the
Informed Consent Form and Demographic Form. The UID selected was assigned to all data
provided by the participant. The participant’s name appeared only on the signed Informed
Consent Form, which was stored separately from the collected data. I had sole access to all data
collected. The median age range of the participants was disclosed with informed consent to
ensure anonymity.
For privacy and confidentiality, interviews were audio recorded on a password- protected
device, such as my laptop computer and smartphone. All gathered data was collected, and audio
files were uploaded to a secure server at Thompson Rivers University (TRU) with a backup copy
saved to a password-protected external hard drive. Only I kept a copy of the password. Once the
audio data was transcribed, the audio file from the secure server was removed. All electronic and
paper files (including audio recordings, signed Informed Consent Forms, demographic
information, and interview transcriptions), as well as the external hard drive, were stored in a
locked cabinet at TRU. This will be retained for five years, per TRU’s policy, and then destroyed
beyond recovery.

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I completed the transcription of the data and ensured that all collected data were deidentified, with all direct identifiers and codes removed to prevent future re-linkage and
minimize the risk of re-identification of individuals through indirect identifiers (Government of
Canada, 2023a). Only the assigned UID was linked to the data. Three participants requested a
one-page statement (executive summary) of the study, which will include key findings,
recommendations and a conclusion based on the data collected.
Data Collection
Data-Collection Procedures
Interview Process
An interview guide comprising eight open-ended questions and associated probe
questions was developed (Appendix I). Probing questions were used to elicit responses and to
enhance data richness. RMs in BC were informed that there were no right or wrong answers and
were encouraged to share their perspectives from their standpoint. Data collection took place
from May 14, 2024, to October 31, 2024, and one-on-one interviews were conducted via TRU
Microsoft Teams. This synchronous online format facilitated participation from RMs in BC
unable to meet in person. Upon mutual agreement on date and time, RMs in BC received a
meeting invite titled “meet with Kimberly” that was sent to ensure anonymity, confidentiality
and privacy. The meeting invite included the date, time, and a meeting link.
Interviews were conducted by the researcher in a meeting space at TRU. This space was
designed to ensure that the environment was uncluttered, private, quiet, relaxed, and well-lit,
thereby establishing rapport, creating a supportive atmosphere, and promoting ease during
interactions. This approach also helped to ensure privacy and confidentiality. I arrived at the
meeting space 30 minutes before the start time to prepare, reading the signed Informed Consent
Form, Demographic Profile, and interview guide, and set aside any personal biases or prejudices

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55

that may negatively affect the conversation by documenting in my journal, personal thoughts,
feelings and reflections.
At the beginning of the interview, I introduced myself and shared, in my own words, the
interview script located on the first page of the interview guide. Then, I turned my laptop camera
around to orient the RM to my meeting space, which held a window for them to see a glimpse of
the TRU campus. This was crucial to set the tone for the rest of the interview.
Then I said, “I want you to feel comfortable as we are just having a conversation, so grab
a cup of tea, coffee or water” to reduce stress before asking interview questions. I asked the RM
to discuss their midwifery practice, how they chose their career, and to share what they enjoy
most about their practice.
At the end of each interview, I asked if there was anything else that I may not have
mentioned that they thought was vital for me to understand, to end on a positive note and to elicit
important information. I also noted that each of the RMs shared in their own words how
comfortable they felt speaking with me after meeting me for the first time. This feedback from
the RMs indicated that the standards for research ethics were satisfied. This strategy was used
because if rapport is not established, participants will not share details with a person that they do
not trust (Polit & Beck, 2021).
Data Recording and Data Transformation
Interviews were audio-recorded on my password-protected laptop computer and
smartphone. Once the data was collected, the audio files were uploaded to a secure server at
TRU, with a backup copy saved to a password-protected external hard drive. I will be the sole
person with access to the password. Audio files were transcribed verbatim with the audio data
conversion feature in Microsoft Word software, then deleted from the secure server (de Chesney,

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56

2015; Polit & Beck, 2021). After each interview, I took the opportunity to write reflective notes
in my journal, capturing my thoughts, ideas, and feelings. I transcribed, listened to and checked
for any issues with the audio recordings. While listening to the audio file and reading the
interview transcriptions verbatim, accuracy was ensured. All identifying factors, such as real
names, email addresses, and phone numbers, were permanently deleted and replaced with the
appropriate three-digit UID to ensure anonymity.
All electronic and paper documents (e.g. audio recordings, signed Informed Consent
Forms, Demographic Profiles, interview transcriptions, reflective notes) and the external hard
drive were kept in a locker with a combination lock (Locker #61) at the TRU Student Union
building (TRUSU). This is referred to as “active storage” (May, 2025). All physical copies of
collected data will be stored for five years and then destroyed beyond recovery. To preserve the
data, the data collected will be digitized and stored on data servers at the TRU Library repository
(TRU Borealis Data Repository) in collaboration with a TRU Librarian and TRU Information
Technology Services (May, 2025). This approach is a stable and secure method for storing and
preserving data.
Data-Analytic Strategies
Data analysis is “the process used to answer the research question” (LoBiondo-Wood et
al., 2018, p. 326). Informed by the CCF and guided by Directed Qualitative Content Analysis
(DQICA), the DQICA research method is designed for qualitative researchers to ensure the
reliability, transparency, and thoroughness of the content analysis (Assarroudi et al., 2018). A
coding template was developed and used as the “organizing framework” for exploring the data
collected and analysis (Sandelowski, 1993). To organize and manage the data, NVivo 12
software (NVivo) was used to upload, store and code the data.

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A six-step analytic schema, as outlined by Assarroudi et al. (2018) and Kibiswa (2019),
guided the data analysis process. The steps included: 1) developing a formative categorization
matrix, 2) developing a coding template, 3) specifying the unit of analysis, 4) immersion in the
data, 5) data condensation and abstraction, 6) data display. Although the steps are presented
sequentially, the analysis process was iterative and nonlinear, involving continuous movement
between the steps. NVivo 12, Microsoft Word and Microsoft Excel software programs were also
used to organize and manage the data.
Step One: Developing a Formative Categorization Matrix
For this first step, a matrix was developed with four categories and definitions informed
by the CCF to guide the analysis (see Table 2). Placement began with a description of the theory
(1st column), followed by the main categories of the theory (2nd column), and operational
definitions that identify words, phrases, and sentences falling under each category (3rd column).
To assign meaning units from the interview transcriptions, in-text identifiers were created and
used, which consist of three numbers and two letters separated by a slash sign (4th column) to
assign to meaning units in the interview transcriptions that I have read.
Table 2
Operational Coding Template
Theory
1. Cultural
Sensitivity

Categories
1.1
Culture/Cultural
identity

2. Cultural
Knowledge

2.1 Generic
Cultural
Knowledge

Operational Definitions
understanding the concept of
culture, your own culture, values,
beliefs and prejudice and the
dynamics of difference and
relationships
Includes basic knowledge of
various cultural groups and
knowledge of cultural groups
served, including cultural issues.

In-text identifiers
111/CS

221/CK

EXLPORING CULTURAL COMPETENCE OF REGISTERED MIDWIVES
3. Cultural
Resources

3.1 Individual
level
3.2 Organizational
level
3.3 Professional
resources

3.4. Social
resources

4.
Assessment
and use of
resources

4.1 Critical
appraisal and use
of resources

Resources developed at the
individual level
Resources developed at the
organizational level
Regulatory bodies, professional
associations, hospitals and health
authorities, research agencies,
Indigenous Bands/Nations
Community groups, community
agencies, legal reports and
documents e.g. Truth &
Reconciliation Calls to Action,
Indigenous cultural safety,
cultural humility, and anti-racism
Access to resources and criticalthinking to apply the resource
appropriately.
Form – printed, electronic,
human or experiential

58

331/IND
332/ORG
333/PROF

334/SOC

441/USE

Step Two: Development of Coding Template
Appendix K displays a summary of the alignment between this study’s four research
questions, interview questions, and proposed data analysis. Additionally, I developed a guiding
tool to address questions in the Demographic Profile. This tool included five columns: the in-text
identifier (first column), a brief description of profile questions (second column), two profile
questions (column three), interview questions (fourth column), and colours used for selected text
(fifth column) (see Appendix K).
Step Three: Specifying the Unit of Analysis
The unit of analysis was verbatim interview transcriptions generated from audiorecorded semi-structured interviews with eight RMs in BC. Meaning units were selected from the
transcriptions where a meaning unit was considered as words, sentences, paragraphs or chunks of
a text (Kibiswa, 2019). I initially focused on the unmistakable (manifest) content, then I

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identified and extracted text segments that aligned with the coding template developed in step
two.
Step Four: Immersion in the Data
To gain a comprehensive understanding of the interview transcriptions, intensive reading
is fundamental (Polit & Beck, 2021). I familiarized myself with the data by repeatedly reading
each interview transcription and listening to the corresponding audio recordings multiple times.
In this step, I identified a meaning unit by highlighting text with different colours (yellow, green,
blue, etc.) (Kibiswa, 2019). A meaning unit can be a word, sentence, chunk of text, phrase, or
paragraph from a unit of analysis (Kibiswa, 2019). I searched and identified meaning units that
corresponded to the coding template I created in step two and assigned in-text identifiers,
bracketed next to the meaning unit (see Appendix M). While reading, I took notes on my
thoughts and ideas for reflection. This approach helped me to make sense of the data. At the
same time, I selected text passages that were deemed rich and thick for the aim of the study and
for any data that did not fit into the coding template were placed temporarily into a separate code
(placeholder) in the NVivo 12 software named “Additional Findings” along with notes to be
analyzed later in the data-analytic process.
Step Five: Data Condensation and Abstraction (Coding Process)
In this step, the meaning units were condensed, abstracted, and then coded according to
the coding template. Data condensation is a "process of shortening while still preserving the
core" of a text (Graneheim & Lundman, 2004, p. 106). Abstraction involves creating codes,
categories and themes at "higher" levels (Graneheim & Lundman, 2004, p. 106). To further
understand my reading and analyzing process, the term ‘code’ was defined. According to
Saldana (2013), a code is a "word or short phrase that symbolically assigns a summative, salient,

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essence-capturing, and/or evocative attribute for a portion of language-based or visual data" (p.
3).
According to LoBiondo-Wood (2018), coding involves designating names to various
chunks of text passages and retrieving and analyzing chunks of data. From the interview
transcriptions, I extracted literal words or phrases spoken by the RMs in BC to generate codes for
analysis (Polit & Beck, 2021, p. 540).
All codes were exported from the NVivo 12 software into Microsoft Excel. To sort and
organize codes, I created a table in Microsoft Word with five to six columns and two rows and
placed the relevant research question above the table. I then reviewed the codes in order of
frequency, from the highest to the lowest, to identify patterns and develop themes, comparing
codes based on their similarities and differences.
Step Six: Data Display
According to LioBiondo-Wood et al. (2018), a data display is “a visual format that
presents information systematically so the user can draw conclusions and take needed action” (p.
330). In this study, I identified four main themes and 15 subthemes to explore RMs in BC’s
perceptions of cultural competence and how they integrate cultural competence into care for
culturally diverse patients. The four main themes —Perception of Culture, Professional
Development and Training, Cultural Influences on Midwifery Care, and Delivery of Midwifery
Care — will be addressed in chapter four.
Data Analysis and Interpretation Beyond the CCF
During data analysis, I identified meaning units that did not match the CCF. In other
words, the text passages for Themes Three and Four were difficult to align or seemed to
contradict the definitions in the Coding Template (Appendix K). One possible reason for this

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mismatch may be due to a significant gap in the CCF, potentially providing an opportunity for
future research. Moreover, this implies that the CCF should be revised, updated and modernized
to remain relevant in the ever-changing field of nursing research. As mentioned earlier,
Carspecken’s (1996) stages four and five of critical qualitative research were adopted to help
explain these unexpected findings that were beyond the scope of the CCF. According to
Carspecken (1996), in stage four, the historical, political, economic, environmental, and social
contexts were considered to analyze the relationships between the social site and the cultural
group.
For this study, the social site for the RMs is the Canadian healthcare system in BC, as
represented in Theme Three (see Figure 4). In the Canadian healthcare system, the idea is that it
is a universal system for everyone, ensuring health equality of access. Stage five involved
aligning these findings with a macro-sociological theory. In this case, the macro-sociological
theory is identified as health equity, which is the ideal goal in healthcare. Carspecken (1996)
noted that a macro sociological theory should be recognized that relates to the findings in the
qualitative study. According to the World Health Organization (2025b), “health and health equity
are determined by the conditions in which people are born, grow, live, work, play and age, as
well as biological determinants” (p. 3).
In BC, the goal is for everyone to access healthcare information, support and services
(Provincial Health Services Authority, 2025). It is not sufficient to only talk about these factors;
participation and a plan of action should be highly considered by nurses (McDonald & McIntyre,
2019; Storch & Scaia, 2014). A few of these strategies are discussed under the heading
“Knowledge Translation” (chapter five). Carspecken (1996) highlighted that this systems
analysis takes you into the world of the participant (insider view), not only to understand their

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interests better but also their surrounding conditions. In light of this, the data was interpreted
with a broader understanding and unveiling of cultural influences in the Canadian healthcare
system, which impacted the work of midwives. This new knowledge can be utilized to address
and improve health outcomes of culturally diverse patients in maternal health settings.
Trustworthiness
To strengthen the trustworthiness of the data and analyses, Lincoln and Guba’s
Framework was utilized throughout the research process (Polit & Beck, 2021). The five criteria
include credibility, dependability, confirmability, transferability, and authenticity (Polit & Beck,
2021). For credibility, semi-structured interviews with eight RMs in BC were conducted for
about 60 minutes on TRU Microsoft Teams (Korstjens & Moser, 2017). The time allotted was
sufficient to engage, build rapport and gather information in a non-rigid manner. The sample
population of RMs was deemed appropriate because they are experts in midwifery and provide
care to culturally diverse pregnant persons daily.
In addition, all interviews were audio recorded with informed consent and then
transcribed by the researcher. Handwritten notes were also recorded in a journal by the
researcher. RMs were informed upfront to indicate if they wanted a copy of the transcribed
interview to make affirm, clarify or edit their response within 10 days. Three RMs accepted this
option, while the other five RMs denied it. Two RMs affirmed their copy, and one RM edited
and returned their responses within the 10-day period. Each interview transcription was analyzed
by me using a coding template informed by the CCF and DQICA in six steps.
Physical observations were not conducted; therefore, three out of the four criteria were met.
For transferability, RMs in BC provide detailed accounts of their perspectives and
experiences verbally (Korstjens & Moser, 2018). The number of years of experience of the

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participants ranged from three to 18 years, which met and exceeded the inclusion criteria for the
study. If considered, the description of the data was sufficient for midwives and nurses and may
be regarded as suitable for interprofessional collaboration. For confirmability and dependability,
an audit trail was maintained, including records of interview transcriptions, logged meeting
dates, completed informed consent forms and demographic profiles, coding templates,
annotations, and notes written in a journal (Korstjens & Moser, 2018). Therefore, this criterion
was met.
For authenticity, exemplary quotes were documented and included in the Findings section
of the study, which also met this criterion (Korstjens & Moser, 2018). Overall, most of the
requirements to enhance the trustworthiness of this study were realized.
Chapter Summary
Chapter Three outlined the methodology used in this qualitative study to explore the
perspectives of RMs in BC regarding cultural competence and how they integrate cultural
competence into midwifery care for culturally diverse patients. It detailed the explorativedescriptive design, participant recruitment and the use of one-to-one interviews for data
collection. The six-step, iterative data analysis process was also described, along with strategies
to ensure the trustworthiness of the results.

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Chapter Four
Findings
The findings of this study are presented according to Journal Article Reporting Standards
Qualitative research design (JARS-Qual) (APA, 2020). As a reminder, the following research
questions were explored in this study:
1. How do registered midwives RMs in BC describe culture in midwifery
practice?
2. What cultural knowledge, skills and resources do RMs in BC utilize to
support the delivery of culturally congruent care in midwifery practice?
3. What are the cultural influences on midwifery care that inhibit or support
the delivery of culturally congruent care?
4. How do RMs in BC integrate cultural considerations of care in practice?
Based on the data analysis in this study, four themes were identified and illustrated in
Figure 2 as a schematic representation of the findings about cultural competence by RMs in BC
for culturally diverse patients which include:
1. Perception of Culture,
2. Professional Development and Training,
3. Cultural Influences on Midwifery Care, and
4. Delivery of Midwifery Care.
Each theme will be presented respectively (1-4), with data extracted from the interviews
to support each theme.

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Figure 2
Themes: Cultural Competence of Registered Midwives in British Columbia, Canada

Demographic Profile of Participants
Eight RMs in BC participated in this study (seven females and one preferred not to say).
Five RMs identified as being of Eurocentric descent. Ethnic backgrounds included Japanese,
Ukrainian, German, South Asian, Indian, First- generation Canadian, Croatian, Portuguese,
Caucasian, White and Western European descent. The median age range was 38 years. Work
experience with culturally diverse participants ranged from three to 18 years. The type of
practice was either solo or with a team, with a range of two to eight other RMs. The cultural
backgrounds of clients included Indigenous, South Asian, White, East Indian, African, Filipino,
West Indian, Caribbean, Jamaican, Mexican, Korean, Japanese, Chinese, Ukrainian, and
Croatian. The characteristics of the participants are shown in Table 3.

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Table 3
Demographic Profile of Participants
Gender

N=8

Female

Work
Race/Ethnicity
Type of
Experience
Practice
Working Team
(years)
3
Japanese, Ukrainian, Team of three
German
7
South Asian, Indian, Team of eight
First-generation
Canadian
5
Croatian, Portuguese Solo

Female
Female

11
11

Female

18

Prefer
not to
say
Female

8

Female
Female

9

Caucasian, White
Western European
descent
White, European
descent
White
Caucasian, Western
European

Cultural Background of Clients
Indigenous
Indigenous, South Asian,
White

Solo
Team of four

African, East Indian, Filipino,
Indigenous, White
Indian, Indigenous
First Nations, West Indian

Team of six

East Indian, Indigenous

Team of two

Caribbean, Chinese, Croatian,
Jamaican, Japanese, Korean,
Mexican
Newcomers to Canada,
Refugees, Spanish-speaking,
Central and South America,
Indian, South Asian, Eastern
European, Ukrainian, 3rd and 4th
generation Canadian

Team of five

Theme One: Perception of Culture
Description of Culture
In response to Research Question 1, the RMs in BC described the culture of midwifery
practice. The perception of culture, cultural competence and cultural safety were described in
their own words. The findings revealed the meaning of these concepts from the perspectives of
RMs in BC. The word “perception” is derived from the Latin word “percipere,” meaning “to
receive, understand” (Vocabulary.com, 2024). It was essential to explore how RMs in BC
described their perception (understanding) of culture, cultural competence and cultural safety
because the description of these cultural concepts is the underpinning for cultural competence in

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their midwifery practice.
The data referred to the RMs in BC’s description of culture in their own words. Some of
the RMs in BC perceived culture as getting to know a patient, as follows:
Understanding who they are, their goals, intentions and the type of
care that they want and honouring what they want for their pregnancy,
labor, delivery and postpartum. That might be some things in certain
communities, there’s the prayer after delivery and no speaking. So,
acknowledging and knowing that that’s something important to this
person. (RM 074)
Values, norms, ways of dressing, food and drink. Communication,
body language, eye contact and a whole range of ways of being, even
expectations of others that are congruent with a group. Sometimes it’s a
shared history. (RM 083)
While some of the RMs in BC perceived culture as race, ethnicity, beliefs, or advice from
generations passed down, for example, songs or stories, some of the RMs shared that culture may
or may not be tied to ethnicity:
If someone is Indigenous, their cultural upbringing might look a
certain way, and that might not be the case. They might have been raised
in a family that wasn’t practising those cultural traditions close to that
culture or they might have been raised by people who aren’t Indigenous
and didn’t have connection to that culture. (RM 038)
Culture isn’t just where you’re born or what your nationality is or
where your parents are from because that’s not right. Like my parents are

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from India, but that doesn’t mean everything that they culturally do, I
culturally do. I grew up in Canada, so my culture is going to look different
than my parents’ culture, which is going to look different from my
grandparents culture. (RM 074)
Conversely, some of the RMs in BC preferred not to describe the meaning of culture:
First of all, it is really understanding our shared history of where
and who we are and the power dynamics, recognizing the histories
and trauma that is involved. The history of basically genocide and
residential school and how families have been thrown apart. (RM 029)
I think our team tries to practice prioritizing the importance of cultural
teachings, cultural knowledge that may be in line or in addition to the
medical care. One of the lessons that I’ve learned on our team is just to
stay very open. I am not the expert in any one culture. All I can do is hold
the space. (RM 092)
I struggle with culture, I don’t identify as having culture, which is
pretty depressing and not totally true, I do have a culture, but I don’t have
the vocabulary or the teachings to feel comfortable even identifying what
it is like. It is like whitewashing or color blindness. (RM 003)
The data of the participants referred to the RMs in BC’s description of culture based on
knowing the patient, characteristics of the patient and attitudes as it relates to culture.
Description of Cultural Competence
The RMs in BC described cultural competence in their own words by expressing their
perspectives using their vocabulary and rephrasing the meaning according to their level of

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understanding without assistance from quoting another person or source of information (e.g.
textbook, Google search engine, social media). Some of the RMs in BC perceived cultural
competence as a relationship, good listening or understanding of a cultural group:
It is a relationship that at any moment can become unsafe because
of the bias and ignorance of the provider not giving enough power to the
person receiving care or not sharing in an equal in that relationship. And
I’m not saying I don’t make mistakes in doing that, but, by not trying to
hold on to power in our relationship, in our therapeutic relationship, by
always trying to like to give that power back, I feel more competent that
people come to me and tell me something needs to change or if they feel
safe or how I can support them in the healthcare system. (RM 003)
It’s about listening to what people’s needs are beyond just the strict
medical care that somebody might be what you perceive as a provider
meaning. I might say, you know you have anemia and I would recommend
iron supplements but also see what are some foods that are high in iron,
because there are so many ways, not just the medication way that we can
help to build health. (RM 092)
I, or practitioners would have an understanding and knowledge in
advance of some of what those customs might be, but it’s a much trickier
term to put into practice because it involves a lot of assumptions and the
assumptions may be wrong. (RM 083)
So, if I think I’m culturally competent with one particular group of
people, it doesn't allow me to maybe recognize that that group may have

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different subcultures within them, whether they live rurally or urban or
they also may be part of a religious community or not that may be different
from the norm of their, for example, ethnic group. Competence is
supposed to imply, I think, that you’re good at maybe already knowing
what somebody might be expecting or wanting you to understand about
them. (RM 083)
On the contrary, some of the RMs in BC expressed that it was difficult to describe cultural
competence:
How on earth could I be competent in this culture or Mexican
culture or Croatia? I can’t begin to be competent to those cultures anymore
than I would expect anyone to know what Minnesotans Scandinavian was
if they hadn’t been there. But cultural competency has always been a hard
word for me because I can’t be culturally competent in your culture
because I haven’t lived in it. (RM 050)
I feel like especially in communities like Canada, where
immigration and we’re all first generation and second generation and
third generation and we’re all essentially like children of immigrants and
migrants. These aren’t exactly the questions I can ask my patients per se
because I feel like I don’t know if a lot of patients would know how to. I
don’t know if someone asked me that how I would answer that question
cause I would wonder, how does that pertain to my care. That is why I’m
like its true, patient centered care in the sense of you tell me what culture
means to you because I can’t define that. (RM 074)

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Here, the RMs in BC describe cultural competence based on relationship, good listening,
and understanding a cultural group. For several RMs, they had difficulty clearly describing
cultural competence.
Description of Cultural Safety
For some RMs in BC’s cultural safety was perceived to be the same as cultural competence
while others perceive cultural safety and cultural competence as completely different terms.
Cultural competence and cultural safety, I would probably think
are pretty similar or describe them similarly. I think of cultural safety and
competence like this idea that I don’t know always what is going to make
a person who’s accessing my care, who is ethnically or racially or
culturally diverse or different from my background, I don’t always know
what’s going to make them feel safe. But trying to have a trauma-informed
approach like know that people might have trauma in their past, whether
it’s to them or it’s generationally. (RM 038)
In terms of cultural competence, it is like actively working, doing
some work, doing training, trying to expose oneself to education around
what is the context of people’s past experiences in health. Like I’m often
thinking about it from an Indigenous history with healthcare in Canada.
What can I actively do to signal to people or to make people how is the care
that I offer to my Indigenous clients may be different than care that I offer
to people who aren’t Indigenous because trying to keep in mind to improve
upon some of the barriers that exist for people who are Indigenous
accessing healthcare. (RM 038)

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I think cultural competence and cultural safety seem like different terms.
Cultural safety would be focusing my attention on ensuring that I convey
an openness and a respect for any range of cultural expressions and
preferences and values and customs. But I kind of see it as an extension of
the general safety that I hope to convey in my care, which would be safety
and openness and acceptance, a curiosity for any range of expression that
may be different. Whether its gender or religious, medical preferences,
whether speaking, education level, that kind of thing. Cultural safety
would be that specific to values and customs and that comes from a person’s
origin, like their heritage, from their family, where they were brought up,
their family of origin or where they currently live or work. (RM 083)
As some of the RMs in BC perceive cultural safety as being approachable, humble and
having an awareness, RM 050 expressed that cultural safety in action means that you must ask
certain questions of yourself:
Can I practice my norms of my culture, whatever that is, in a way that I
don’t get teased about or shamed about or bullied about or received less
safe care than someone else? And oftentimes that someone else would be
then the mains whatever the mainstream and the current culture you’re
living in.
Similarly, RM 092 shared:
I guess cultural competency is the education and the care delivery side of
things and then cultural safety is the experience side of things. Like if
you’re in a healthcare and medical system that is culturally competent,

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then I think your experience will be that you’re seen as a whole person
and that you have a safer experience within the healthcare, you’re more
likely to return to healthcare, you’re more likely to access healthcare in a
timely way. At the core, it’s about being respected and not having the way
that you live your life seen as a nuisance or be denied.
Interestingly, RM 029 expressed that cultural safety is specific to Indigenous peoples
in BC:
When you say, cultural safety, it’s very specific to Indigenous people in BC
and the idea is kind of the framework that they use and the terminology that
they use for Indigenous populations and in BC. And it’s different than the
rest of the country, even in terms of meeting Indigenous health needs,
mostly because most of the province is not treaty, so there haven’t been
agreements with the First Nations of BC and so there are a lot of kind of
politics behind it.
To summarize, the RMs in BC’s description of cultural competence are both similar and
different terms, as they relate to cultural competence, including being approachable, humble, and
having awareness of others’ beliefs, culture, and worldviews. Moreover, cultural competence is
critical to Indigenous peoples in BC. Having established the underpinnings of cultural
competence, the alignment of Theme One with the CCF will be explored in the next section.
Description of Cultural Sensitivity
The data related to the first theme, ‘Perception of Culture’, described how the RMs in BC
perceived themselves. It is essential to note that the demographic characteristics, specifically the
columns for gender and race/ethnicity in Table 3, were repeated by the RMs in BC, followed by
religion and heritage and in addition to gender identity, several RMs in BC reported "cisgender,

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she/her pronouns" (RM 092) and "queer" (RM 050). Moreover, several RMs in BC described
race/ethnicity as "people of color" (RM 029) and "Indian" (RM 074). The reported religions were
"Catholic upbringing/culture" (RM 038) and "non- religious" (RM 092). Several RMs in BC
described their heritage or marriage. For instance:
"I am married to a Persian. My mom is from Trinidad and Tobago, my dad is
white Canadian, my grandmother is ¾ Chinese, ¼ Spanish, and my grandfather
was half Indian, half East Indian, ¼ Black, ¼ Carib". (RM 029)
"My dad is Croatian, my mom is Portugues, and both worked hard." (RM 012)
"My husband is Scottish." (RM 038)
RMs in BC also described how others perceived them, such as an ally, doctors, settlers,
inexperienced midwife or culturally safe providers:
Perhaps they see me as white Anglo-Saxon, middle-aged, able-bodied, female. If
they read my bio available on my clinic website, they may also see me as a mom
and someone raised rurally. It is common for midwives to post a personal bio
accessible to clients and their families so that they can know us a bit as people.
Because I'm their care provider, depending on where their country of origin
and aspects of their background such as education level or profession, they may
see me as an expert in what is best for them and in a position of power. Or maybe
they look down on me because I am a midwife rather than one of the physicians I
work with in our team. Culturally diverse patients may have assumptions about
me and my professional role that are distinct from assumptions or beliefs of
patients that have similar backgrounds to me. (RM 083)
I think, interestingly, older South Asian clients see me as inexperienced

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and would prefer another midwife. I think most other culturally diverse
patients / clients may find a level of comfort in a midwife that may have
a better understanding of their lived experience especially if they are also
a racialized person even more specifically in health. (RM 074)
If you’re asking how they see my race, it is likely as a white Canadian
woman. We often end up sharing cultural identities, understanding,
perspectives later into care (if it comes up) so they often end up seeing me
as a white American with Canadian citizenship. Sometimes they learn I
am queer, but not always. I don’t think the Minnesota-Scandinavian
identity is seen as much more nuanced and only sometimes do I expose it.
(RM 050)
The data quotes from the RMs in BC, as presented above for Theme One are aligned with
Cultural Sensitivity. Therefore, this finding is deemed congruent with the first interlocking circle
of the CCF and should be kept in mind to gain insight into the ways in which the RMs in BC
integrate this knowledge into midwifery practice. Theme One demonstrated a complex, diverse
understanding of cultural concepts and cultural identities of the RMs in BC which was crucial to
further explore cultural competence in midwifery practice.
Theme Two: Professional Development and Training
In response to research question two, Figure 3 displays a thematic map of the cultural
knowledge, skills and resources RMs in BC utilized to support the delivery of culturally
congruent care in midwifery practice.

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Figure 3
Thematic Map: Professional Development and Training

Cultural
Knowledge
Theme Two:
Professional
Development &
Training

History and
Culture of
Canada
Educational
Modes of
Delivery
Individual
Resources

Cultural
Resources

Organizational
Resources
Professional
Resources

Cultural Knowledge
For cultural knowledge, the RMs in BC shared generic and specific knowledge. RM 038
shared that this knowledge related to care in the hospital and community. For instance:
We have had Indigenous clients who want to do smudging, and so at our
hospital there's a protocol in place. It's pretty easy. It's not like the first
time we were trying to figure this out. It was like we had to talk to
engineering and make sure they can turn off the smoke alarms and you
know, it was kind of a process. But now that that process is in place, it's
very simple. And so, there's already a protocol in place at the hospital and
how to support that.
And then the other thing that comes to mind is in terms of
postpartum care. The public health message for sleeping with babies has
always been, historically, to have your baby sleep on a separate surface

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than you in the same room. Well, the context is that we know that most
families at some point bring their baby into bed with them. There are
certain times when I really, really don't recommend it, for example, if a
baby is born preterm or if there's anyone who smokes cigarettes in the
house, these are high risk scenarios for babies having sleep accidents.
When we're doing home visits postpartum, sometimes we'll go
into a home of a patient who is Punjabi or from India and I can see that
they don't have a bassinet for their baby. I can see that the plan from the
beginning is that baby's going to sleep in bed with the parents. And that
is the cultural norm. One of my patients said, “Well, where I'm from, no
one sleep, no, no, your baby does not sleep separate from the mother,
like, that would never happen.” (RM 038)
Moreover, RM 074 shared this knowledge related to issues of religious beliefs during care:
For example, if you need a blood products in your care, would that be
something that you would agree or consent to or is that something that you
would not consent to. Most people would consent to it unless they're of
that belief, ethnic or religious belief.
When I have my Muslim clients come into my care there were
direct questions that I asked them because I know a little bit more because
I've worked more with the Muslim population. Like the prayer that they
have in baby’s ear when babies are born and the silence that follows after
a delivery. I know that because I've worked in those communities and so
I will pointedly ask people. So those pointed questions for me, at least will

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only arise if I've experienced it, and I wish that I knew everything for me
to be able to ask that question because I feel like especially for first time
parents, they might not know to ask, or they might feel like they can't ask.
And so how do we create opportunities for people to ask their healthcare
providers? (RM 074)
This reference to power was further identified and is continued from the previous
statement by RM 074:
Because there was a bit of a power play happening there even when we try our
best to knock those structures of power down. I feel like, asking more perhaps,
what is it at different stages, maybe adding, is there something you culturally
need to be aware about to better support you and honor you in the pregnancy?
Can you start to think about these things for your labor and delivery so we can
help facilitate that? (RM 074)
RM 003 explained the meaning of power in their own words:
What I mean when I mentioned power, it has more to do with like any sort of
system, right? Like in a healthcare system oftentimes, if you're, you know, being
cared for by someone, there is this like power play at hand where you know we
have all the information and the patient doesn't have all the information and
perhaps the patient or the client feels like they can't be their true authentic self.
(RM 003)
In the subcomponents of Cultural Knowledge, the concept of power emerged in the data of
RMs in BC to understand what cultural knowledge, skills and resources were used to support the
delivery of culturally congruent care in midwifery practice. Furthermore, in the theme of

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Professional Development and Training, the RMs in BC shared the need to understand the history
of Canada and disclosed educational modes of delivery used for obtaining cultural training,
resources and tools.
History and Culture of Canada
The RMs in BC emphasized that it is vitally important to understand Canada's history.
Specifically, as it relates to the repercussions of colonialism and the continued oppression of
Indigenous Peoples in healthcare, this knowledge is not only relevant for newcomers to Canada
but even for locals: “Canada is its own country, with its general traditions...We need to be open
to other cultures now. Remember, not everybody is white. Not everybody is what you are” (RM
050). This finding highlights the importance of understanding Canada's historical context to
provide culturally congruent care.
Educational Modes of Delivery
Along with understanding the historical context of Canada, RMs in BC employed various
educational modes of delivery to gather cultural information through different learning
platforms. RMs in BC described the way they sought after and developed cultural knowledge
through books, handouts with culture-specific content (e.g. brochures, pamphlets, etc.), cultural
training updates received via work email, virtual training courses to obtain professional credits,
attending a conference to listen to keynote presenters, in person work training and the Internet,
just to name a few.
Although virtual learning was convenient, RMs in BC stated that some health
professionals are "burned out" from print-based and virtual learning. Some RMs expressed that
their learning was most effective when done in a team or community setting rather than in a solo
training environment. "I feel like also just having conversations with my fellow care

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practitioners, because like you know, everybody has so much that people have, like, experience
and knowledge to share" (RM 012). They found this collaboration to be more beneficial for
relationship building, planning care, and debriefing. This finding is consistent with the CCF's
characteristics and demonstrates how cultural knowledge is understood and acquired by
Registered Midwives (RMs) in BC.
Cultural Resources
Individual Resources
RMs in BC hold post-secondary education from recognized midwifery programs and
have completed entry-level competencies with the nursing regulatory body, BCCNM. Beyond
tertiary education, RMs described the individual resources they used from experience in their
midwifery practice.
Like when I have my Muslim clients come into my care there was direct questions
that I asked them because I know a little bit more because I've worked more so
with the Muslim population, right, like the prayer that they have in baby’s ear
when babies born and the silence that follows after a delivery. (RM 074)
RM 038, a fluent speaker of Spanish, shared their experience while working in a remote
community: “I used to work at a birth center in Texas and I spent a lot of time working with
Spanish speaking clients we would have looked into some translation services had it not been
that I could do visits with her.”
Moreover, RMs in BC spent time in the community, along with their child, to learn the
native language, experienced a sense of belonging in the small community in which they lived,
for example, when they meet patients in public places such as the swimming pool or the grocery
store.

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Organizational Resources
All RMs in BC completed the San'yas: Indigenous Cultural Safety Anti-Racism Learning
Programs for cultural understanding. This was noted as a mandatory online training course for all
of the RMs in BC. Although RMs have undergone the San'yas training, participants reported the
limited resources available to RMs in BC. For example, one RM shared the availability of
translator services:
There are translator services, but I feel like the few times that I've heard it talked
about in the hospital, like families that have zero English. You know, translator
services are only available from nine to five, or you have to pay long-distance fees
or face all these other barriers that seem to make it more challenging. So, I find
unfortunately more reliable is Google translate or family members, which I find
isn't appropriate (RM 012).
Professional Resources
Predominantly, RMs in BC obtained information from regulatory bodies, professional
associations and health authorities on materials related to cultural competence. In BC,
organizations included BCCNM, Provincial Health Services Authority and First Nations Health
Authority. Other organizations were located in different provinces, such as the National Council
of Indigenous Midwives in Quebec, Ontario Midwives and the Registered Nurses’ Association of
Ontario in Ontario. These findings demonstrate that cultural resources are accessible to RMs in
BC; however, their use can be limited when providing care to culturally diverse patients.
Theme Three: Cultural Influences on Midwifery Care
In response to research question three, RMs in BC identified the cultural influences on
midwifery care that inhibit or support the delivery of culturally congruent care in midwifery
practice. This applies to locals and newcomers in the Canadian Healthcare system. Sociocultural

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factors and influences were identified. Figure 4 displays a symbolic representation of cultural
influences on midwifery care.
Figure 4
Symbolic Representation of Cultural Influences on Midwifery Care

Consider
the Cost of
Care

Incongruence
During Care

Pressures
Across
Care

Dominant Culture of Society

In Figure 4, the funnel represents the Canadian healthcare system in this case. At the top
is wide and the bottom is narrow. The top means that all are welcome to healthcare services. The
bottom represents limited access to healthcare. Dominant culture of society means the social
norms or customs in a society; in this case, it is the healthcare system in BC.
Consider the Cost of Care
RMs in BC considered the cost associated with midwifery care, such as fees, health
insurance issues, limited transportation and birth evacuation.
The prenatal care isn't as bad, but for birth, if you end up having the Csection, it's usually minimum $20,000 that they would have to pay out of
pocket and get billed for it. And you know, even just to get blood work
is $400.00, right? So, people hold off getting necessary tests or blood

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work and stuff….consult with an obstetrician, if we
have concerns, that's $1,000. It adds up very quickly. (RM 029)
RM 029 also mentioned that oftentimes patients do not access services if they must pay,
they fear having an outstanding bill which could affect the patient’s application for permanent
residency.
For health insurance, RM 038 stated that approval for magnesium supplements was
delayed for a patient from First Nations, despite their eligibility under the health plan. Other
aspects considered by RMs included poor housing, limited resources, low income, and limited
transportation for travel to birth or office visits. These findings show that considering the cost
was high not only for delivery but also hinderances to access and use of maternal services.
Participants spoke of their concerns about the financial burden that childbirth can entail:
I think that a lot of those patients who I've worked with they are,
you know, like income is limited and resources are limited. And then other
barriers like kind of system barriers that I've encountered are like I have a
client right now who she is just needing a few extra supplements. They're
not even prescriptions, but they're just a few extra like supplements that I
recommended for her and because she's Indigenous, she qualifies to get all
of those paid for, but the way I had to prescribe it was like so confusing
the public health nurse from the Nation like walked me through it and it
still was really confusing. I ended up sending the prescription like three
different times because it wasn't written correctly and I just hadn't
encountered this before because usually when I tell a person and I
recommend a magnesium supplement. (RM 038)

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It’s been more to do with social demographic than culture. So, a
white person with this low socioeconomic status, I see there were a lot of
them were declining care for their baby and like so MCFD, like child
service was threatened to be called and stuff because of the history. In my
limited experience, it is more so are they poor are they uneducated and are
they already being judged or what the care provider think is a lack of being
able to make good decisions. But I think if you look at the evidence too,
minorities are typically in that, yeah demographic and there are a lot of
barriers. (RM 012)
So sometimes what the situations we might see folks coming from
different communities, would be in medical terms, usually called an
evacuee. Somebody who doesn't have birth service available in their home
community or that they're not eligible to receive the services in their home
community because maybe they're risks of like they're too high risk to be
birthing in communities, so then they might end up flying down to a
bigger tertiary center like a city to receive health care at a higher level of
hospital. (RM 092)
Incongruence During Care
Incongruence during care were described by the RMs in BC which means that they did
not meet their care goals and expectations as planned. At the same time some RMs stated that
there are still other influences there but “invisible”, for example, “generational trauma”,
A lot of the other barriers I think are like invisible and ones that I
don't I believe are there, I just don't know to see them. I don't know what

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about my office set up or the hospital might be signaling this is not a safe
place or this is a safe place. It's just not always clear because I'm not from
the culture and I don't have that historical trauma and the, you know,
generational trauma to know what kinds of things are feeling unsafe,
because I'm sure there's plenty of them around that I just don't even know.
(RM 038)
This subtheme reflects the perspectives of the RMs in BC as it relates to making
mistakes, miscommunication, mistrust and misunderstandings. RMs in BC spoke about the
disconnect between their professional expectations and what they could actually do for patients
within the limitations of their practice and perhaps their cultural knowledge.
It is definitely systemic in that the expectations don't match the reality of
what providers are supported to do. And now there's the extra layers of like a bit
of hypocrisy like. Our birthing culture isn't designed to support people. The
hypocrisy I was alluding to is like we say, we're patient centered and we say we're
trying to do these things that are going to make people feel such and such, but it's
all still on our terms. (RM 003)
One of the RMs in BC commented on how expectations can differ from client to client. RM
050 shared their experience with the spouse of one of their patients after labour as illustrated below:
But even two nights ago, I was at birth and the dad said to me, [spouse] “I thought
I was going to be here for the whole surgery”. There was a miscommunication between
the two of us about how mom has to get prepped.
[spouse] “Well, what does prep mean?” [RM 050] “Prepared”.
[spouse] “Which is prepared? Let's define preparation”

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He was very concerned about leaving his wife. He was protecting her and they
started the surgery without him. He was there for the birth and he was super upset about it.
And I didn't understand that at all. And in the moment I was like, well, everything's fine. I
was here and then at home and thought about it. I was like oh, but in his culture he was
protecting her. And I didn't allow him to do that, you know. So, I still make huge mistakes
because to them that's really a big deal. (RM 050)
I think there was miscommunication and there were just different expectations,
right of why it would not have occurred to me that it would have been important for him
to be there when someone cut into his wife. Like it just didn't, you know. He was going to
be there for the birth. That was the important part, right. And I was exhausted and when he
said it, I dismissed him. I was like, she's fine. And then on reflection, I was like, oh, but I
could have said you expected to be here. It was important for you to be here and just let
him have his feelings. Let him be frustrated. Let him be upset. Right? (RM 050)
There were discussions about some patients not trusting people intending to help and
support them, as well as the risk they feel with getting involved with the “system” like MCFD.
The acronym MCFD means Ministry of Childre and Family Development, which is a child
protection service in Canada:
There's a ton of distrust, you know, it's like families do not want to be
connected with MCFD, but it is kind of the only way to get people help. I don't
know, it's really hard, families who have been involved with MCFD in the past
often are like they'll do anything to avoid that. Yeah, because the context is
sometimes people…their kids are taken away. (RM 038)
Several of the RMs in BC noted their challenges with communicating effectively to avoid

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misunderstandings and assumptions,
I do remember like her saying, like how hard that birth was and
just feeling so like. So sorry that I failed her. But maybe that's just really
egotistical, like maybe birth is just really hard and there wasn't anything
that she needed differently from me. She certainly didn't say it
postpartum either, but I could just feel the weight of a cultural like
misunderstanding. (RM 003)
I'm not sure how else that influences my care, but I do think
those are the kinds of things that I wonder about in terms of, like the
invisible. The invisible like context of my assumptions I'm making in
the world, and the invisible context of this system, how people are
accessing care. Like things that I don't see because even though there is
more like diversity in society now than, you know, 50 years ago. (RM
038)
For example, a client wanted to stay in the community, but they
were being told by a specialist that they should leave so we wouldn't
make a care plan for everybody. But where there's some discussion that
needs to be communicated between clients and different care providers
and we want everyone to be on the same page. I would see that as my
role of making a care plan that reflects the needs and expectations and
values of my client and disperse that to the maternity ward and their
specialists. (RM 003)
These exemplars illustrate the tension RMs encounter in their everyday practice. The work

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to avoid miscommunication and provide culturally safe care is critical to the care they provide for
all midwifery clients and families.
Pressures Across Care
Pressures across care, reflected the RMs in BC’s perspectives as it relates to power and
language barriers. RM 003 explained the meaning of power:
What I mean when I mentioned power, it has more to do with like any
sort of system, right? Like in a healthcare system oftentimes, if you're, you
know, being cared for by someone, there is this like power play at hand where
you know we have all the information and the patient doesn't have all the
information and perhaps the patient or the client feels like they can't be their
true authentic self.
Language differences affected care, particularly during labour, if a
family member who is translating steps out of the room. Sometimes language
barriers can lead to instances where cultural traditions are not honoured, for
example, requests for a female physician rather than a male physician. RMs in
BC suggested that workplace issues such as stress, burnout, intimidation and
language barriers can inhibit quality care. “I do think the resources are there.
But I think most practitioners are so burnt out from like print based or even like
YouTube video-based learning.” (RM 003)
Participants emphasized the stress caused by what they felt was the power of the system
over their clients and their own practices:
It's really stressful and sometimes they don't access care to the
same extent because they have to pay. And you know, like, especially if

EXLPORING CULTURAL COMPETENCE OF REGISTERED MIDWIVES
they have an application for permanent residency or anything like that, if
you owe the health system a significant amount of money for birth or
something that can impact on your ability to even get permanent residency
and so on. (RM 029)
Like our system still is intimidating and it's easier to just behave
and follow the rules, especially in a country that you are new to than to
say like, this isn't working for me. What are my other options? Can we
explore that together? And you don't you don't necessarily know as the
provider when someone is agreeing to everything. (RM 003)
Because there was a bit of like a power play happening there even
when we try our best to knock those structures of power down. What I
mean when I mentioned power, it has more to do with like any sort of
system, right? Like in a healthcare system oftentimes, if you're, you
know, being cared for by someone, there is this like power play at hand
where you know we have all the information and the patient doesn't have
all the information and perhaps the patient or the client feels like they
can't be their true authentic self. (RM 074)
Having family included at the labour or the birth is something that
we're happy to do of course, that was a big challenge over COVID, so that
was a big issue. COVID made things a little more difficult, so in providing
care to folks who wanted to have lots of people at birth or and when birth
is a jubilant occasion in a culture and people are excited and they're
laughing and they're happy and expressing joy, which is wonderful. It's

89

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usually really upsetting for the hospital staff, right. So that can be a really
big challenge. (RM 050)
Sometimes language is challenging, especially like in the stress of
labour. You know if people are overtired or the partner stepped out of the
room and they don’t have a translator or something just sometimes just
those language barriers or you think you have an understanding and then
something happens you know like oh we meant this. I'll find language to
be a big barrier sometimes. (RM 012)
These findings reveal the historical, political, social, economic, and environmental
influences that inhibit or support the delivery of culturally congruent care.
Theme Four: Delivery of Midwifery Care
In response to research question four, namely how RMs in BC integrate cultural
considerations of care into practice, RMs in BC explained in detail how they incorporated
cultural values, beliefs, and traditions into the birth plan during the prenatal, labour, and
postnatal periods. The work of integrating cultural considerations in midwifery practice is in the
Five-Phase Cultural Considerations of Care Model (see Figure 5). These five phases include 1)
Assessment, 2) Care Approaches, 3) Documentation, 4) Goals of Care, and 5) Referrals and are
summarized in Table 4.

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Figure 5
Five-Phase Cultural Considerations of Care Model

#1 Assessment
#2 Care
Approaches
#3
Documentation
#4 Goals of
Care

#5 Referrals

In Figure 5, the model illustrates five overlapping processes involved when RMs in BC
integrate cultural considerations into care practice. Each process is measured to determine the
congruency of care in the birth plan. Measurement is not an instrument tool, but an ongoing
reflective evaluation of the level of congruency of care. These processes were formulated from
the data and re-presented by the researcher. It is important to note that the processes is not a linear
approach to care.

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Table 4
Developing a Birth Plan in Midwifery Practice
Phases
#1 Assessment

Purpose
Informed choice,
initial visit

Conceptual Meaning
Really focus on an individual as an individual
but open the conversations and open the care
relationship to being that first. So early on in
the care, I ask questions like, it's important to
me that what's important to you comes forward
throughout your care and you and I will have a
long relationship, almost a year, and usually
there's other people involved in the care (R083)
I think that it's really easy as a white person
who thinks that they are like sensitive and
culturally sensitive to just think, “you know,
my care is good for everyone, like those
systematic racial inequities that exist, they
don't exist in my practice”.
You know, I think it's really easy to think that
(R038).
Birth plan document to our clients that they can
like trim and alter. So, like we will start with
conversations in the clinic where people you
know we can have a dialogue, but then they
can also go home and talk about it with their
partner or their families and then bring that
information back to us. It’s not all one and
done. It’s definitely a fluid conversation. And
then we also offer the birth planning document
(RM 012).

#2 Care Approaches

Attitude Check

#3 Documentation

Written for other
health
professionals

#4 Goals of Care

Based on the
Code of Ethics

We're all about safety. Like, it's all about safety.
And if that person feels safe, the rest will come
(RM 003).

#5 Referrals

Refer as needed

Elders, Indigenous birth workers like doulas in
the community. (RM 092)
Phone number available 24 hours a day, seven
days a week, for urgent concerns or anything
they would take themselves to the emergency
room (RM 050).

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Phase One: Assessment
On assessment, the RMs in BC begin by interviewing patients to collect data during the
perinatal period. RMs noted that, unlike a doctor who may spend five to ten minutes with a
patient, they spend at least 30 minutes with their patients, explaining everything firsthand. This
finding of thirty minutes allotted to patients is very significant. This finding indicates that care
visits are managed within a reasonable timeframe. RM 074 explained that cultural considerations
are included in the birth plan because of time:
In midwifery we really try to only take on a certain number of patients so
that we can ensure that we are having these 30-minute-long appointments or
longer for some people. That's why we are able to ask that question I think perhaps
more so than other people are because we have that time built into the way that
we provide care. In fact, specific approaches were taken by some of the RMs in
BC to address some of the cultural influences mentioned earlier, for instance:
We try to be upfront as quickly as we can, but you know, even when
they’re just meeting, we send them the cost of how much things cost and so
on. Just so people have an understanding, an idea. (RM 029)
It also means sometimes when I get to like put forward different ways of
doing things, that we have really rich conversations about why that wouldn't work
for them and why they need something different - that isn't what I would choose
and those conversations actually allow me to be curious and push them a little and
in response I get a really strong message about what is important to them. (RM
003)
We start from the very beginning in British Columbia, everyone has to

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choose what we call one primary maternity care provider, and you can have a
family doctor if you're lucky enough to have one or what we call a general practice
doctor, which is often used interchangeably. Or you could have a nurse
practitioner and a nurse and we talk about what a nurse practitioner is, they are
specialist doctors who treat the complications. (RM 050)
And we talk about the specialist doctor and then we talk about midwives
and how we're not medical doctors, but that we did go to four years of medical
school for midwifery and we do this, that we all have to do the same chart, that
no matter if you have any one of these care providers you should all still be
getting the same labs the same ultrasounds. So, really trying to lay it out so that
it's clear that there is a path. There's literally a pathway called the maternity care
pathway. We talk about that. You can access that if you want to look at it and see
what is to be expected or what they can expect in their care. (RM 050)
As demonstrated above, on assessment RMs in BC have a reasonable timeframe to
establish a good rapport, opportunities for conversations about culture and the capacity to
integrate cultural considerations into the birth plan when providing care.
Phase Two: Care Approaches
The RMs in BC described care approaches utilized to elicit what is
important to the patient, their families and communities, for instance: “I'll find the
most respect for my clients when I believe that they're doing the best they can for
themselves with the information that they have.” (RM 003)
RM 012 may study health resources that categorize foods as ‘healthy’ for a particular
cultural group, however, the information is not imposed during patient interaction. RM 012

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further explains as follows:
When I was in Vancouver, they had specific resources on early pregnancy
based on different languages and health eating – there was an Asian bowl because
most Asian culture eat out of a bowl - so, I think overall I try to approach it with
like curiosity. Yes, this is typically what we do, this is typically what's offered,
but I'm all ears in terms of how else we can make you (the patient) more
comfortable and honour, you know, the traditions of your family. (R012)
Similarly, RM 074 shared their understanding of the challenges in being perceived by
others as being different and the power differentials these perceptions raise. For example:
Because I know what it's like to navigate, especially health systems or
systems that were made for people who don't look like me, primarily for white
people, right. Like our education systems or health systems, they weren't
necessarily created for people of color. And that doesn't mean that white people
don't have culture. They do. It's just they're at the top of the hierarchy and people
that look like me and other like and especially my Black and Indigenous clients,
they're at the bottom of the hierarchal pyramid. (RM 074)
And what can I do to better support these people. And I know that because,
like, I've personally experienced it and my family has personally experienced it
right. And so I feel like I walk into this space, the clinician, knowing what it's like
to sit opposite healthcare providers, sit opposite a professor, sit opposite a public
servant and feel like, you know, I'm not respected in the same way or I'm not
given the same amount of information or I'm not receiving the same type of care
or education or what have you. (RM 074)

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And always approaching care in this way of how to best show up for this
person, especially my clients of color or my culturally diverse pregnant patients.
And the only way I can know that is by asking those questions and sort of
dropping my ego because there isn't space for that, especially not as a healthcare
provider when I'm the person that has the power, I have all the information you
don't. It's my job to present that to you and to learn about you to give you the best
type of care. (RM 074)
I also feel like I need to try not to hide that I don’t know everything and
to have this openness to things, like this where I know, like I don't know all these
definitions and I don't know that because that curiosity and that openness, just
improve my approach in midwifery care. (RM 012)
Phase Three: Documentation
For documentation, the RMs in BC began asking the patient about their racial, cultural or
ethnic identity. Several RMs in BC expressed that it can be uncomfortable asking patients about
their ethnicity because the patient does not understand the meaning of the question. Three
examples of RMs in BC explaining the documentation phase are illustrated below:
For any patient, we talk about birth plans and what their birth preferences
are. Some people will have a written birth plan that we submit to the hospital with
their records. So that's for any client. But for people who are Indigenous we just
kind of asked specifically, are there any cultural practices or anything you want us
to know about what you're wanting or not wanting during your labor and birth?
(RM 038)
We don't really use anything special unless somebody wants to

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use something special. I'm aware in BC anyway, we have there's a
passport to pregnancy and one is focused on everybody and then one is
focused on First Nations. I don't, I have offered that tool to be used to
folks who identify as First Nations, but usually when we say what are
you hoping for the birth and keep it really open-ended. What are you
hoping for, here's what to expect. (RM 050)
We also might offer the birth plan document to our clients so that
they can like trim and alter. We will start with conversations in the clinic
where people can have a dialogue, but then they can also go home and
talk about it with their partner or their families and then bring that
information back to us. It’s not all one and done. It is definitely a fluid
conversation. (RM 012)
Phase Four: Goals of Care
Most of the RMs in BC emphasized that safety is one of the most important goals of care.
RMs stated: “If we're truly doing informed choice, there is cultural competency in there because
it is allowing someone to make a decision based off of what they deem to be appropriate” (RM
074). Another RM in BC added: “We're all about safety and if that person feels safe, the rest will
come. So, anything that's going to increase the feeling of safety should be the first thing that we
do (RM 003). RMs spoke about how they provide respectful care that takes into consideration
many cultural perspectives and individual circumstances:
I hope people feel safe around me and know that my kindness is
genuine and I do you really want to get to know them and know what's
important to them and do the best that I can to support them within the

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constructs of what is provided here in BC. In terms of a specific example,
recently we had a client that we were talking about the birth and I
mentioned some medications we use. And she's like, oh, well in Nigeria
I use a couple of herbs and this massage, but you know...So I said, Let's
see where you can integrate this. (RM 012)
Acknowledging and recognizing the intersectionality of people
right, so what you see and what people share with you. There's always
more to that, right? Like you sure I'm a woman, but I'm also a South Asian
woman. I'm also a South Asian, first- generation Canadian woman. I'm
also a child of migrants. I'm also a like, the first time someone’s graduated
university in my family, you know, like there's all sorts of these types of
intersectionality of people and that's the part of like, although I'm never
going to get to know 100% of you in a short amount of time that I'm with
you, I'm hoping that we have the privilege of spending so much time with
people in midwifery care that I get to learn these pieces of you or a little
bit that can give me then the amount of information that I need to give you
the best care that you can receive. (RM 074)
Phase Five: Referrals
For referrals, the RMs in BC referred patients to free phone translation services, provide a
phone number in case of emergency, and volunteer programs:
We just recently used a translation system that can be used on the
computer at the hospital, which was very helpful because there was some
complex care that we didn't really know if they were understanding what

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we were saying to the family. So that was really helpful. We have a
volunteer program and just like to get some networks of friends and so on
as well, because it can be quite isolating, especially in a small town. (RM
029)
In addition, RM 012 stated that:
“When we're able to see them at home and like, get to meet, you know,
their other kids and their partners or like, you know, encourage all their support
people”.
Moreover, RM 038 mentioned that: “We have a project in our community
trying to increase access to like breastfeeding support, peer support and like
professional support for breastfeeding” as well as RM 092 said, “We have
community connections and make referrals and connect our clients with Elders,
Indigenous birth workers, like doulas in the community. We apply for grants to
be able to get grocery store cards for families.”
Chapter Summary
The purpose of my qualitative study was to explore the perceptions of RMs in BC about
cultural competence and how they integrate this knowledge into midwifery care. I found that
RMs in BC perceived culture in various ways. RMs in BC possess a variety of resources, tools,
and skills for professional development and training. They have identified multiple cultural
influences that affect midwifery care and demonstrated how they integrate their knowledge of
cultural competence into practice through a step-by-step approach. In Chapter Five, the
importance of these findings, nursing implications, and recommendations for future research will
be discussed.

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Chapter Five
Discussion
This chapter discusses the findings presented in chapter four under the four themes:
1) Perception of Culture,
2) Professional Development and Training,
3) Cultural Influences on Midwifery Care, and
4) Delivery of Midwifery Care.
The first theme, Perception of Culture, includes definitions of culture, cultural
competence, and cultural safety from the perspectives of RMs in BC, and explains how this
knowledge is translated into midwifery practice when providing care to culturally diverse
patients. The definitions set the foundation, followed by discussions on cultural sensitivity,
which align with the CCF (Srivastava, 2023). The second theme, Professional Development and
Training, encompasses talks on Cultural Knowledge and Cultural Resources, drawing on the
CCF. As mentioned earlier, the text passages in the data exceeded the scope of the CCF, and
Carspecken’s (1996) stages four and five were used for further analysis. Therefore, the third and
fourth theme provides further interpretations by identifying findings that did not align with the
CCF and/or the literature. Later sections include the limitations of this study, its contributions to
the field, nursing implications, conclusions, and knowledge translation.
Theme One: Perception of Culture
Interpretation of Culture
In response to research question one, namely, RMs in BC describe culture in midwifery
practice and define culture in their own words. While there were no right or wrong answers, most
of the RMs in BC found it to be challenging to define culture. This finding is consistent with past
researchers who have also struggled to define these terms, resulting in a universal meaning that

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remains undetermined and unclear (Capper et al., 2023; Marriott et al., 2019; Williamson &
Harrison, 2009).
Srivastava (2023) stressed that understanding the concept of culture is fundamental to
developing cultural competence. Although this may be true, this study confirms that culture is not
a concept that can be easily defined or understood. One possible reason for this difficulty is the
diversity of cultural identities. Therefore, the meaning of culture can vary depending on the
context. Nonetheless, this finding revealed definitions from the perspectives of RMs in BC,
which provides a step to building the foundation of developing cultural competence in midwifery
care.
Interpretation of Cultural Competence
Similarly, RMs in BC defined cultural competence in their own words, with the freedom
to speak openly. Many of the RMs in BC described cultural competence with ease. For example,
cultural competence means having a relationship, demonstrating good listening skills or
understanding a cultural group. The RMs in BC’s ease in defining cultural competence correlates
with past literature (Abualhaija, 2021; Blanchet Garneau & Pepin, 2015). For Burton and Ariss
(2014), several midwives were “empathetic” and had “past experiences with so many different
cultures” (p. 277).
On the contrary, other RMs in BC expressed that cultural competence was difficult due to
inexperience residing in a different cultural environment or the awkward feeling that arises when
the term is mentioned. This finding implies that there are alternate reasons, besides having
experience, that the concept could be easily defined. While being informed and having
experience are essential, this finding suggests that a negative connotation is associated with
cultural competence, which past literature has failed to describe.

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Interpretation of Cultural Safety
Likewise, RMs in BC defined cultural safety in their own words. Most of the RMs in BC
defined cultural safety from different perspectives, which is consistent with scoping and
literature reviews that suggest that there is no universal definition for cultural safety (Capper et
al., 2023; Williamson & Harrison, 2020; Wilson et al., 2022).
Several RMs in BC associated cultural safety with cultural competence, while others
distinguished between the two concepts. Moreover, RMs in BC defined cultural safety as
“action” (RM 050) of self and referred explicitly to “Indigenous populations” (RM 029). Both
perspectives on cultural safety are informed by recent studies that highlight the importance of
intentional, active engagement to ensure cultural safety (Aerts et al., 2024; Bourque Bearskin et
al., 2025; Tomkins et al., 2024).
Interestingly, many of the RMs in BC did not find it challenging to define cultural safety.
One reason for the ease in defining cultural safety may be the vast amount of information
available from government sources, social media, and professional and regulatory organizations
about cultural safety. Surprisingly, cultural safety is not known globally in healthcare. This was
the case for Pirhofer et al. (2022) in a study of 29 advanced practice nurses, who reported that
cultural safety was not commonly understood and that limited background knowledge about
cultural safety resulted in poor treatment outcomes. Yet, Sarmiento et al. (2022) conducted a
study in 80 communities in Mexico involving 30 midwives to support cultural safety. This effort
reduced perinatal complications, and cultural safety in childbirth was improved. The
underpinning of cultural competence is determined by the definitions of culture, cultural
competence and cultural safety reported by the RMs in BC.

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Interpretation of Cultural Sensitivity
This study found that RMs in BC perceived themselves in terms of ethnicity, race, gender,
religion, and heritage. These cultural identities refer to “culture as patterns” (Srivastava, 2023, p.
60). This finding aligns with the concept of Cultural Sensitivity in the CCF (see Figure 1). This
implies that RMs in BC are quick to describe their sense of identity based on the shared
traditions of a cultural group, physical features (e.g., skin pigmentation, hair, facial shape), sexual
orientation, religious beliefs, or heritage. This finding is unusual because the majority of the
RMs in BC declared their identity based on physical characteristics (visible) rather than personal
traits (intangible), such as personality, virtues, behaviours, and advocacy.
Interestingly, RM 029 reported “person of color,” which refers to a marginalized or
racialized population, and RM 003 reported “without much cultural identity”. One of the reasons
these categories are provided may be due to the shift in the cultural environment of healthcare
during the COVID-19 pandemic and the profound impact of systemic racism and discrimination
also found by past researchers (Aerts et al., 2024; Boakye et al., 2023; Kimani, 2023; Odems et
al., 2024; Olukotun et al., 2024; Turpel-Lafond (Aki-Kwe), 2020; Vaismoradi et al., 2022).
RMs in BC described how others perceived them based on their ethnicity, race, gender,
and socioeconomic status. These cultural identities refer to “culture as power” (Srivastava, 2023,
p. 61). This finding also aligns with Cultural Sensitivity in the CCF (see Figure 1). Surprisingly,
RM 029 reported “person of color,” and similarly, RM 074 noted “a midwife who may have a
better understanding of their lived experience, especially if they are also a racialized person.”
Interestingly, RM 083 reported:
“If they read my bio available on my clinic website, they may also see
me as a mom and someone raised rurally. It is common for midwives to post a

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personal biography accessible to clients and their families so that they can know
us a bit as people.”
These findings are significant and highlight cultural identities that are notably important
to the individual and are often overlooked due to prejudice, bias, discrimination, and even
stereotypical ideas. There appears to be good evidence that racism and discrimination are
becoming prevalent in nursing (Aerts et al., 2024; Boakye et al., 2023; Kimani, 2023; Odems et
al., 2024; Olukotun et al., 2024; Turpel-Lafond (Aki-Kwe), 2020; Vaismoradi et al., 2022).
Theme Two: Professional Development and Training
In response to research question two, namely what cultural knowledge, skills and
resources RMs in BC utilize to support the delivery of culturally congruent care in midwifery
practice aligned with the second and third interlocking circles of the CCF (see Figure 1).
Cultural Knowledge
RMs in BC shared their cultural knowledge, skills, and resources utilized, and described
how they went about seeking and obtaining cultural training, resources, or tools to use in
midwifery practice. In addition, they were asked to describe the type of training, resources and
tools used in midwifery practice. Formal education was obtained from a Bachelor of Midwifery
degree program. General knowledge was pursued through traditional and non-traditional means
at the individual, professional and social/community levels.
History of Colonialism in Canada
RMs in BC also emphasized the importance of knowing the historical context of Canada.
It was noted in the CCF that social resources would include the Truth and Reconciliation
Commission of Canada: Calls to Action (TRC Calls to Action), visiting a residential school in
the community, and legislative acts and laws in Canada, such as the Indian Act, Multiculturalism

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Act, and United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP), among
others. However, these were not explicitly described by the participants. The seven Calls to
Action specifically for health (numbers 18-24) outlined in the TRC Calls to Action and the
UNDRIP indicate that Canada recognizes the harms and rights of Indigenous peoples
(Government of Canada, 2024c; Government of Canada, 2024d).
The pressures of care are also influenced by the clarion call for cultural competence in
the Canadian healthcare system, issued by governments, regulatory nursing bodies, and
professional nursing organizations. Under the Medicare Protection Act of 1996, eligible
residents can enroll in the Medical Services Plan (MSP) for medical services provided by
doctors, RMs, dentists, or eye exams, among others (Government of BC, 2025). Yet without
enrollment, high fees are incurred for maternity care. While this information was not identified in the
data, the Canadian government, nursing professional organizations and regulatory bodies through
healthcare initiatives and programs have emphasized the importance of these cultural resources
(BCCNM, 2025; CAPWHN, 2024; Association of Ontario Midwives, 2025).
Cultural Resources
Individual Resources
RMs in BC reported that there were limited resources about cultural competence outside
of the materials provided by the BCCNM. Findings from previous studies also confirm that
limited resources are available about cultural competence. Darroch et al. (2017) found cultural
competence embedded in position statements and organizational policies. However, there were
only a handful of studies on strategies to improve cultural competence in health care (Clifford,
2015; Gabrysch et al., 2009; Handtke et al., 2019).

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Organizational Resources
Similarly, Marriot et al. (2021) stressed that professional development needs to focus
more on improving understandings of cultural birth practices and health system changes, which
create safer maternal health care environments for Indigenous pregnant women. Moreover,
incorporating cultural safety courses into the nursing curriculum can also enhance knowledge
among midwives (Thackrah et al., 2020). All RMs in BC completed the San’yas: Indigenous
Cultural Safety Anti-Racism Learning Programs for cultural understanding. San’yas is a
mandatory online training course for all healthcare professionals in Canada.
The training course was developed in 2008 by Indigenous educators in BC. The term
"San'yas" means "way of knowing," and the program is a model based on decolonization and
addressing Indigenous-specific racism through training and consultation (San'yas Anti-racism
Indigenous Cultural Safety Education, 2025). Several studies have found that midwives lack
knowledge of Indigenous pregnancy traditions and have poor cultural education (Marriott et al.,
2021; Pirhofer et al., 2022).
Professional Resources
Although the literature revealed the necessity for resources to be readily available, for
RMs in BC, this finding revealed the lack of resources that are supplied and utilized.
Theme Three: Cultural Influences on Midwifery Care
In response to research question three, RMs in BC shared the cultural influences on
midwifery care that inhibit or support the delivery of culturally congruent care with locals and
newcomers in the Canadian Healthcare system. The RMs in BC identified cultural influences on
midwifery care that inhibited or supported the delivery of culturally congruent care. It is essential
to recognize that the participants in this study provide care to culturally diverse patients daily and
were aware of these issues during the perinatal period. Sociocultural factors and influences were

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identified (see Figure 4).
Consider the Cost of Care
The RMs in BC expressed that without MSP coverage, patients incurred high fees, which
became difficult to pay due to socioeconomic factors such as limited access to food, education,
housing, insurance and financial resources. It is essential to recognize that social determinants of
health significantly impact culturally diverse patients, including income, food and housing
security, and access to healthcare and social services (Government of Canada, 2024b; Raphael,
2016).
These social factors have been acknowledged in Canada for decades; however, the social
determinants of health have not been adequately addressed (Storch & Scaia, 2019). This can be
stressful and result in underutilized care due to barriers, especially financial constraints (RM
083). Even with MSP coverage, RM 038 mentioned that they prescribed for an Indigenous
pregnant patient. However, it took weeks before approval due to multiple back-and-forth
meetings with the insurance company and a significant amount of paperwork. It is essential to
acknowledge that this is a political and social issue that has significantly impacted midwifery
practice. While efforts have been made by healthcare organizations, healthcare delivery is
hindered because the focus shifts more toward the patient's status rather than their overall wellbeing (Association of Ontario Midwives, 2025; Elias & Larios, 2024; Jarvis et al., 2019;
Kornelsen et al., 2023; McLachlan et al., 2022).
According to D'Souza and Leslie (2023), multiple healthcare providers are involved in
providing care during the perinatal period, including doctors and obstetricians. Regarding
financial resources, RMs in BC sometimes apply for grants on behalf of their patients to cover
expenses such as acupuncture or massage fees, grocery cards, transportation services for

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appointments (e.g., taxi), and housing. It was noted that there were no incentives for preparing
these applications and no guarantee that the applications would be approved. This service was
offered in kind and was not billed to patients. Again, it is essential to note that these activities are
not within the scope of practice for midwives, and this highlights, once again, the socioeconomic
issues that impact midwifery practice and need to be addressed.
Incongruence During Care
The RMs in BC expressed a lack of trust in the healthcare system, particularly after the
COVID-19 pandemic. Besides the inundated protocols from the pandemic, in some cases, when
patients accessed care, their children were taken from them by social workers. In other cases,
patients were mistreated by healthcare professionals. As a result, many patients did not return for
follow-up visits. Similarly, researchers have found that a lack of trust can significantly influence
the outcome of care, particularly in the postpartum period (Akter et al., 2020; Chopel, 2014;
Sivertsen et al., 2025). Moreover, mistrust arises from negative experiences in maternity
healthcare settings (Marriott et al., 2019; Niles et al., 2021; Vang et al., 2018). Ultimately, trust
must be rebuilt to establish rapport with culturally diverse patients, encouraging them to access
care and fostering meaningful relationships. Rapport is foundational during interaction with
patients.
Pressures Across Care
Surprisingly, the findings from the data on cultural influences on midwifery care do not
align with the CCF. The Canadian healthcare system is the social system under consideration in
this study. The RMs in BC shared their experiences with culturally diverse patients who were
either new to or familiar with the Canadian healthcare system in BC.
The concept of power emerged in the data of RMs in BC to understand what cultural

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knowledge, skills and resources were used to support the delivery of culturally congruent care in
midwifery practice. Srivastava (2023) highlighted that the issue of power often occurs during
patient interaction with various cultural groups. This issue is described as unequal power or
power distance, where the patient is reluctant to ask questions to prevent conflict, or the
healthcare provider abuses their power because they believe they know more than the patient
(Srivastava, 2023). This was incongruent with the CCF because power dynamics did not occur
due to cultural identity or the title of being a healthcare professional, as alluded to by Srivastava
(2023).
Instead, power emerged due to the Canadian Healthcare system in which the RMs in BC
were employed, and the pressures that came from the system, rather than from the patient or
healthcare provider. Interaction was influenced more by the system. Even Carspecken (1996)
puts it differently, stating that power is considered equal when no one has more say than the
other. Therefore, the outcome is mutually understood. RMs made efforts in BC to destroy this
“power play” during care (RM 074). This finding is consistent with previous researchers. For
example, Niles et al. (2021) found that healthcare professionals encouraged patients to conduct
their research, especially when preparing their birth plan, to ensure "self-advocacy and selfdetermination" (p. 8). The implication here is that RMs in BC recognize the power in the system
and, rather than enforcing it, efforts are made to dismantle power structures (RM 074).
Concerning other influences, some RMs in BC expressed a lack of continuity of care.
This hindered the ability to know and support cultural preferences because patients lacked a
choice due to staff shortages (Canadian Midwifery Regulators Council, 2022; Hanson et al.,
2013; Hanson et al., 2024; Thiessen et al., 2020; Thompson, 2020).
For Indigenous pregnant persons living on the reserve, there is a policy to travel off the

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reserve for childbirth (D'Souza & Leslie, 2023; Silver et al., 2022). Studies have shown that
Indigenous pregnant women experience feelings of isolation from their families because part of
their traditional practice is home birth or being surrounded by healers, Elders and friends during
labour (Corcoran et al., 2017; Kolahdooz et al., 2016; O'Driscoll et al., 2011). These traditional
practices should be viewed and treated as valuable by healthcare professionals, especially when
outlined in the TRC Calls to Action.
Several RMs in BC mentioned that during COVID-19, it was challenging for many
people to be in the labour room during childbirth (Perera et al., 2023; RM 050). This is consistent
with the literature. For example, traditional smudging ceremonies were not possible due to
hospital restrictions. There were also cultural preferences for a female doctor rather than a male
doctor, which in most cases could not be met due to staff shortages. The findings in Theme Three
align with the literature, which confirms that cultural issues are prevalent in midwifery care.
Overall, the cultural influences that inhibited were more dominant than the support for culturally
congruent care due to the system in which the RMs in BC worked daily.
Theme Four: Delivery of Midwifery Care
In response to research question four, this study revealed how RMs in BC integrate
cultural considerations of care in practice, which misaligns with the CCF. One possible reason
for this misalignment between the CCF and this study could be that the CCF needs to be revised,
updated and modernized. The RMs in BC described a Five-Phase Cultural Considerations of
Care Model, composed of Assessment, Care Approaches, Documentation, Goals of Care, and
Referrals (see Figure 5). It is no surprise that developing a birth plan for culturally diverse
pregnant persons involves a systematic approach to guide the plan of care.
Importantly, RM 083 referred to informed choice during the initial visit during the

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Assessment phase, then RM 038 emphasized checking one's attitude during patient interaction in
Phase Two. RM 012 highlighted the need for Documentation, which included written
communication for other health professionals. Furthermore, RM 003 emphasized the importance
of "safety… it's all about safety". Followed by RM 092, who added that Referrals were made for
culturally diverse patients, which involves collaboration with other healthcare professionals to
provide patient care. This indicates that the RMs in BC explicitly identified a process necessary
to incorporate cultural considerations of care into practice for culturally diverse patients.
D'Souza & Leslie (2023) expressed that health care professionals should 'carefully walk
through' the birth plan with people. According to D'Souza and Leslie (2023), "family- centered
prenatal (maternal) and newborn (neonatal care) involves respect for cultural differences…while
following the essential principles of care. RMs in BC use a form called a birth plan (p. 300). A
birth plan "outlines labour and birth preferences of a pregnant patient and their support people
and is a good strategy to help prepare patients for birth" (D'Souza & Leslie, 2023, p. 300). With
this in mind, the primary goal of midwifery care is to provide respectful care to ensure a safe
delivery. Unexpected situations may arise, which is why other care providers are involved in the
coordination of healthcare delivery during the perinatal period, including doulas, chiropractors,
family doctors, obstetricians, and registered midwives, among others (D'Souza & Leslie, 2023).
Given that the RMs in BC described five phases, it was anticipated that, as previous
researchers indicated and recommended, there is a need for practical ways to incorporate culture
into the care of culturally diverse populations. Capper et al. (2023) emphasized that in midwifery,
a midwife is required to understand Indigenous cultural birth issues, including cultural awareness
in their midwifery practice, with actions that support an Indigenous woman to feel safe when
accessing maternity care. Blanchet Garneau and Pepin (2015) reported in a study involving 24

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healthcare professionals and students that cultural competence enhances care provided to
culturally diverse patients when integrated into practice.
Moreover, Okere (2022) emphasized that cultural competence in practice builds rapport,
alleviates patient treatment errors and ensures patient-centred care. Researchers have found
studies from 2002 to 2016 that outlined strategies to improve cultural competence as it relates to
policies, procedures, training, conducting ongoing audits in healthcare organizations in New
Zealand, Canada, the USA and Australia at the individual and organizational levels (Akter et al.,
2020; Handtke et al., 2019; Jongen et al., 2018; McCalman et al., 2017).
Although the literature confirms the need for cultural competence, it lacks a step-by- step
model for practice, as provided in this study. One possible reason is that past literature has
presented the experiences and perspectives of culturally diverse patients. In contrast, the
experiences and perspectives of midwives in Canada regarding cultural competence are limited.
The model in this study revealed a new structural pathway to navigate diverse cultural
preferences, ensuring high-quality health outcomes when providing care to culturally diverse
patients.
Limitation of Study
This study was my first nursing research conducted in post-secondary formal education
as an international student to explore the perceptions of RMs in BC about cultural competence
and to gain insight into how they translate this knowledge into midwifery practice. Although this
study presents some positive findings related to the research questions and the use of the CCF,
certain limitations could be addressed for future research. For example, the sample of eight RMs
limits the generalizability of the findings to other healthcare disciplines.
This study could be improved by analyzing data from the federal, provincial and

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municipal levels about cultural concepts such as culture, cultural competence and cultural safety
in midwifery and nursing practice to identify meanings, patterns or gaps across Canadian
provinces and territories. This approach can be used for future research to shed further light on
government policies and programs, to address issues and develop policies and practices to
improve health and healthcare issues of culturally diverse patients. Moreover, this study could be
improved by conducting a mixed method research study, for example, using a combination of
interviews and questionnaires to collect data to enhance interpretations with RMs and
policymakers or community partners.
This study does not cover cultural concepts based on maternity data at the federal,
provincial and municipal levels. Future research using federal, provincial, and municipal
maternity-related data from other Canadian provinces may shed further light on cultural concepts
and cultural competence, contributing additional evidence to midwifery care in Canada.
I conducted semi-structured interviews, lasting approximately 60 minutes, with eight
RMs in BC. Despite this, the open-ended questions allowed participants to explore the key
components of this study, and their experience and expertise generated rich data to meet the
study's aim. The study could be improved by conducting four to five focus group interviews,
each comprising four to six experienced midwives, in a comfortable setting for 120 minutes, to
discuss cultural competence in practice. In addition, observations, for example, conducted over
six months to one year in clinics and hospitals to observe the daily routines of midwives,
followed by face-to-face interviews, could improve the study.
The transcribed interview transcriptions were returned to three RMs to affirm, clarify or
edit their responses within 10 days. The study could be improved by providing a draft one- to
two-page summary of the results for midwives to review and verify the accuracy of the

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summary. I analyzed each interview transcription using a coding template informed by the CCF
and DQICA, following six steps. The study could be improved by researching other sources,
such as policy documents, to develop a broader understanding of cultural competence, which
continues to evolve.
Contribution to Field of the Study
This study will be the first to be conducted at Thompson Rivers University by an
internationally educated nurse from The Bahamas (Appendix N). This study has identified
cultural influences on midwifery care in BC and developed a Five-Phase Cultural Considerations
of Care Model, which may be used by other researchers, policymakers, and community partners
to consider and address cultural issues, ultimately moving toward resolution. With limited
experts in the field, I hope that this study inspires a passion to advance the training that is crucial
not only for creating awareness but also for implementing cultural competence into practice in
BC actively.
This study may also encourage community partners to consider new approaches to
cultural competence in the healthcare system that extend beyond the use of virtual platforms to
collaborate with surrounding communities. This collaboration may involve small or large group
educational training programs held in person, as well as focused groups to brainstorm new
policies, procedures, and even clinical guidelines for evidence-based practice. This study’s
methodology may also help novice qualitative researchers develop their methodologies when
conducting research.
Nursing Implications
The CCF utilized in this study was the first to be used at Thompson Rivers University for
research of RMs in BC. Due to the limitations of the CCF, Carspecken’s (1996) critical stages of
analysis were employed to analyze the data further. After this analysis, the complexity of the

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cultural issues were thoroughly considered. To resolve these issues, further investigation is
required, which falls beyond the scope of this study. In light of this, the researcher will pursue a
Doctor of Philosophy in Nursing to extend this study beyond the master’s level, aiming to
influence change and advocate for the optimization of quality care for culturally diverse patients.
Significance to Education
This study can enhance the critical thinking and judgment of nursing students, professors,
and professional organizations such as the Canadian Association of Schools of Nursing (CASN),
the BCCNM, and the CNA. Particularly, for educators, to foster cultural competence into the
educational space, through academic policies, nursing curriculum, course outlines, lab
simulations, assignments and activities for teaching and learning, educational training and with
specific, measurable, achievable, relevant and time bound learning objectives and outcomes for
faculty, staff and students.
The educational information from this study can raise an awareness of the historical
origins of Canada, completion of formal and professional education of RMs in BC, cultural
knowledge and limited cultural resources, and the strategies used to incorporate their
understanding of culture into practice. Topics, critical questions, and discussions can be
formulated from this study and compared with those from other provinces in Canada to develop
local, provincial, and global conversations that promote cultural competence at the start of
midwifery and nursing programs.
Moreover, clinical practicums for midwifery and nursing students can enhance the
theoretical knowledge obtained concerning cultural competence and to develop practical skills in
this area. For example, hands-on training opportunities for teaching and learning experiences
through supervised visits in the community, community-based clinical simulations followed by

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evaluation methods, such as debrief meetings, discussions and reflections (RM 038; RM 092).
Ultimately, the development of an educational plan in partnership with communities to
incorporate cultural resources and tools, for example “cheat sheet” to help mitigate poor health
outcomes and experiences resulting from culturally incongruent care (RM 012).
Significance to Nursing Practice
One of the aims of this study was to provide significant information that supports
empirical research on cultural competence in midwifery practice. This can contribute to both
midwifery and nursing practice by raising an awareness of the impact of culture on healthcare as
demonstrated through the literature review and the findings of this study. Understanding and
interpreting knowledge from research can help RMs and RNs develop their personal and
professional skills to become actively engaged in healthcare scenarios they face on a day-to-day
basis with culturally diverse patients, thereby encouraging better health outcomes. Data from this
study can train and equip RMs and RNs with practical steps to achieve cultural competence and
integrate cultural considerations into their practice. Health promotion and initiatives can be
formulated based on this study for RMs and RNs to implement in the plan of care for individuals,
families, and communities.
Cultural competence is a process and is often mistaken for a task (RM 003; RM 074).
This study can debunk this approach to cultural competence, and instead, RMs and RNs may
adopt new perspectives and attitudes that embrace cultural diversity. Nursing associations and
regulatory bodies can be more actively involved in their communities through educational
seminars, workshops and forums on the influences of culture on healthcare, and to obtain
feedback from the communities on their cultural needs.
Moreover, these findings suggest several potential nursing interventions to enhance

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cultural competence. For example, one suggestion was the development of a quick reference
guide on the cultural competence of culturally diverse patients, especially for RMs and RNs
returning from an extended leave of absence from practice. Another example was a commitment
to ongoing, rather than one-time, team meetings before and after delivering care to culturally
diverse patients for debriefing, brainstorming, and sharing feedback to effect change. This
requires being intentional about taking action to provide culturally competent care.
Significance to Future Nursing Research
The healthcare environment is dynamic. As we continue to move further into the 21 st
century, it is essential to recognize the emerging healthcare workforce. The combination of RMs
and RNs from Generation Z and Generation Alpha with those from established generations, such
as Generation X and Generation Y, requires skills and abilities to understand different needs and
wants as a team (Ashley et al., 2020). These relationships then transfer into care and
understanding of culturally diverse patients. Therefore, internal cultural training through research
is necessary to maintain balance in the workplace. There is a high expectation from this group,
and the contribution of nursing research has become increasingly significant in improving both
workplace relationships and relationships with patients.
The introduction of advanced internet and mobile technologies, such as Google, Bing,
ChatGPT, Artificial Intelligence, and digital platforms like Facebook, WhatsApp, YouTube,
Instagram, and TikTok, has influenced how we prepare RMs and RNs for the future
(Government of Canada, 2024a). The rapid technological change has created a demand for
innovative curricula developed to provide teaching strategies for further development. Nursing
research offers a formal approach to learning, enhancing critical analysis and interpretation. This
study can contribute to nursing research, as a theory was tested and the findings provided new

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insights into RMs in BC and how they understand and integrate culture into practice. This is
important to keep in mind when creating evidence-based clinical guidelines or promoting
effective use of technology to guide thinking skills and behaviours in nursing.
Significance to Health Policy
There is a dire need to reduce inequalities and promote health equity in BC. Some
culturally diverse patients have limited access to healthcare, social determinants of health, poor
housing conditions and in some cases homelessness due to historical, social, cultural, political
and economic reasons. RMs and RNs collaborate with physicians, obstetricians, pharmacists,
physiotherapists and social workers to develop a plan of care for individuals, patients and
communities. As mentioned earlier, Indigenous people still face challenges due to public policies
that still affect the way they are seen in the healthcare environment. These views create stigma
that prevents the desire to seek health care services not only for Indigenous people but also for
anyone who may not be part of the dominant society or is new to a dominant culture.
This study aims to promote culturally congruent care for culturally diverse patients. RMs
and RNs can determine to take action to address and resolve specific issues in their society by
becoming actively involved through engagement with key officials in a professional manner.
RMs and RNs should consider networking with policymakers and healthcare community partners
in-person or digitally, communicating with decision-makers through social media, presentations,
briefing notes, or letter writing.
I hope that this research will inform policies aimed at reducing health inequities,
improving poor health outcomes, and enhancing the experiences of culturally diverse patients.
Total engagement, attention, and complete understanding of governmental bodies, professional
organizations, policymakers, community partners, and other public officials are necessary for the

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development of policies that influence the health of culturally diverse patients in BC and are
designed to create a model of culturally congruent care.
Recommendations for Future Study
No evidence was found to match or support the Cultural Care Action and Decision
Modes of the CCF. One possible reason for this mismatch may be due to a significant gap in the
CCF, potentially providing an opportunity for future research. Moreover, this implies that the
CCF should be revised, updated and modernized to remain relevant in the ever-changing field of
nursing research. To fully capture the meanings of culture, cultural competence and cultural
safety were difficult for the researcher during analysis. For example, the findings could not be
thoroughly analyzed with the framework alone; therefore, Carspecken’s (1996) stages four and
five of critical qualitative research were employed.
For future research, it is recommended that all five stages of Carspecken’s (1996) critical
qualitative research be utilized which was not employed due to the extensive time required to
conduct observations and interviews. Also, it is recommended that the CCF be updated to
include Carspecken’s (1996) systems analysis along with the Five-Phase Cultural Considerations
of Care Model for RMs and RNs. One of the reasons is that the systems analysis approach
examines the social, economic, and political conditions in which healthcare professionals operate
daily and the relationship between these conditions and the data collected is determined.
This study unveiled systemic social structures in the Canadian healthcare system that
would not have been recognized within a positivist paradigm. Using Carspecken’s (1996) critical
analysis theory, the study generated findings and interpretations that will contribute to the body
of nursing knowledge related to cultural competence, both locally, provincially, and globally.
Further research is needed to consider the historical, social, economic, and political context of

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cultural competence in midwifery practice across other Canadian provinces, to make
comparisons and provide more detailed answers to the questions raised by this study.
A prolonged, longitudinal critical ethnography study can be beneficial to examine
cultural practices, attitudes, and behaviours that are demonstrated on a day-to-day basis.
Moreover, it is recommended that comparative research about the perspectives of cultural
competence between Indigenous RMs and non-Indigenous RMs about cultural competence, as
well as their experiences of providing care to culturally diverse patients.
The findings from this study can inform the development of clinical practice guidelines,
clinical assessments, clinical skills, standards of care, specific nursing interventions, culturally
based workshops on cultural considerations in care practice, and programs and health initiatives
aimed at improving health outcomes and experiences for culturally diverse patients. I hope that
this study will elicit further investigation into this complex phenomenon.
Conclusions
The purpose of this qualitative study was to explore the meaning of culture from the
perspectives of RMs in BC and to investigate how this knowledge is applied in diverse,
multicultural healthcare environments. Data was collected from semi-structured interviews. The
CCF served as the guiding framework for this study, addressing four research questions.
Directed content analysis was applied to analyze the data, which was then organized into four
themes based on the CCF. Two themes aligned with the CCF, but the other two themes did not
fit into the CCF. Those findings required further investigation of the data, as they could no
longer be analyzed using the existing framework.
In the final analysis, the data highlighted obstacles related to the political, historical,
social and economic context, and secondly, the data identified strategies to resolve some of those

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hurdles. These findings identified a significant gap between the data and the CCF. A component
that involves an in-depth analysis of the issue, leading to a specific strategic plan of action. For
this reason, Carspecken’s (1996) stages four and five for critical qualitative research were
utilized to investigate those findings further. This approach led to interpreting the data at a
meaningful level. Significant data was identified to suggest the need for future research in
education, practice, research and policy related to cultural competence in midwifery practice.
Overall, the findings from this study provided valuable information and insight into the
perceptions and experiences of RMs in BC related to cultural competence. The information
obtained may be used to develop clinical assessments, guidelines, policies and practices that will
enhance understanding of cultural competence in midwifery care. This study has enhanced my
knowledge of the perceptions and experiences of RMS in BC and how cultural competence is
applied to midwifery practice in diverse multicultural healthcare environments.
Considering all things, a newborn does not choose a culture, but we, as healthcare
professionals, have a responsibility to ensure that every newborn receives safe, respectful, and
culturally competent care. How does culture influence your practice?
Knowledge Translation
To begin, I would use the schematic map of the knowledge-to-action (KTA) coupled with
integrated knowledge translation (Graham et al., 2006; Nguyen et al., 2020; Straus et al., n.d.). I
will develop a plan of action by first considering the cost to conduct KTA and the financial
support available. Deciding to enroll in a university and pursue my Master of Nursing degree is
one formal way of increasing my knowledge of the cultural competence of RMs in BC.
Conducting this study has enabled me to gain a deeper understanding of the importance and
significance of cultural competence in midwifery practice. For participants to view this study, I

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can send an email to each participant with a Uniform Resource Locator (URL) or website link to
access Thompson Rivers University’s Institutional Repository, named TRUSpace, which includes
a collection of scholarly materials and documents available to the public (May, 2025). To retrieve
this study, a 16-digit number associated with this study will be provided for ease of reference (May
2025).
Knowledge translation would also involve organizing training seminars and workshops in
universities, health clinics, and hospitals for healthcare professionals, policymakers, community
partners, and nursing regulatory bodies. I will disseminate the results at the CASN’s Biennial
Canadian Nursing Education Conference and publish a peer-reviewed manuscript in the Journal
of Transcultural Nursing (Transcultural Nursing Society, 2025). I can conduct educational case
studies, visit and engage with local Indigenous communities, schedule face-to-face meetings
with public officials, arrange academic conferences, coordinate podcasts featuring guest
speakers, and host small workshops and focus groups. Following engagement and networking,
these activities will be scheduled on a month-to- month basis, with quarterly debriefings and
evaluations conducted over five years.
Cost-effective strategies I will employ include letter writing to administrators,
government officials, and community partners in BC, such as the Ministry of Health or Interior
Health. I will utilize social media platforms such as YouTube, WhatsApp, Facebook, Twitter, and
Instagram to host webinars, facilitating opportunities for regional and global networking (Palmer
et al., 2017). All in all, it is essential to recognize that the process of research to practice will take
time, and consistent, open communication with decision-makers is crucial (Graham et al., 2006).
Wright (2015) stated that nurses have a significant role to play in promoting a sense of
belonging to provide culturally congruent, safe care. Nurses who are committed to providing

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high-quality care should base their practice on professional standards of ethical conduct
(International Council of Nurses [ICN], 2021). The moral tradition of nursing is self- reflective,
enduring, and distinctive, and it should be guided by the ICN Code for Nurses – to provide highquality care regardless of ethnicity, race, culture, or gender (ICN, 2021). The CCF provided a
theory-guided method to make culture visible accurately. Still, Carspecken’s (1996) critical
analysis unveiled the complexity of the issue by considering the historical, political, social, and
economic contexts of cultural competence in midwifery practice.
In the final analysis, if healthcare professionals, specifically midwives, fail to
acknowledge or integrate cultural considerations of culturally diverse patients, dissatisfaction in
maternal health services, delayed healing and poor maternal health outcomes will persist.
(Kleiman, 2006; Wright, 2015). Midwives can deliver change in midwifery care for culturally
diverse patients through beneficial, culturally congruent, high-quality care by utilizing a phased
approach.

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Appendix A: Research Ethics Board Approval - TRU

147

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Appendix B: Certificate of Ethical Approval – Interior Health

148

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Appendix C: Institutional Approval – Interior Health

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Appendix D: Recruitment Poster

150

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Appendix E: Invitation Letter to Midwifery Organizations

151

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Appendix F: Invitation Letter to Registered Midwives

152

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Appendix G: Informed Consent Form

153

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Appendix H: Demographic Profile

157

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Appendix I: Semi-Structured Open Inquiry Interview Guide

158

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Appendix J: Chart for Searching Literature
Database (12 months)

Results (Dated 05-Jun2025)

Limit - Canada

CINAHL

318

8

MEDLINE

790

29

MEDLINE (with Full Text)

438

38

PsycINFO

85

0

Academic Search Complete

1,130

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Formulation of Keywords Searched
Cultural competence of Keywords searched
Registered Midwives in
British Columbia,
Canada
Research questions
1. How do midwives Cultural
Midwives
(P) in BC describe competence
culture (O) in
midwifery
practice?
2. How do midwives Synonyms
(P) in BC
integrate cultural
considerations of
care in practice
(O)?
Culture
3. What cultural
Health care
knowledge, skills
professional
and resources (I)
Cultural sensitivity Maternal
do midwives (P)
health
utilize to support

Search Words and
Truncations Used

Canada

AB ("Cultural
Competence" OR
"Cultural Safety"
OR "Cultural
sensitivity" OR
"Cultural
awareness" OR
"Cultural humility"
OR "cultural
awareness"
OR "cultural
Province congruency" OR
"cultural
appropriat*"
British
OR "Culturally
Colum
congruent" OR
bia
"Cultural profic*"
OR "Cultural
compassion" OR

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162

Cultural safety
the delivery of
Pregnant,
culturally
pregnancy
congruent care in
Cultural awareness Perinatal
midwifery
practice (O)?

"Cultural
empathy" OR
Indigenous OR
aboriginal OR
immigrant) AND
("Midwif*" OR
"Maternal" OR
"Perinatal" OR
"Antenatal" OR
"postnatal" OR
"postpartum" OR
"birth" OR
"childbirth" OR
"antepartum" OR
pregnancy)

4. What are the
Ethnicity,
Antenatal,
cultural influences
postnatal,
Cultural diversity
(I) on midwifery
labour,
care (P) that
Cultural difference postpartum,
inhibit or support
birth,
Immigration
the delivery of
childbirth,
culturally
Transcultural
antepartum,
congruent care
nursing
(O)?
Cultural diversity,
cultural awareness,
cultural sensitivity,
cultural
congruency,
cultural
appropriateness and
cultural safety.
Culturally
congruent care
Cultural
proficiency
Cultural humility
Cultural caring
Cultural
compassion
Cultural empathy

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163

Appendix K: Coding Template
Research
Interview Questions
Operational Meaning
Questions
RQ 1 – How do midwives in BC describe culture in midwifery practice?
IQ2- In healthcare, there is a vast amount of
Understanding the concept of
information from the government,
professional organizations and social media
about culture, cultural competence and
cultural safety. If you had to explain what
these concepts mean to you in the simplest
way, how would you explain it?

IQ7- How does your culture influence your
practice?
Probes:
- Give an example
- How would you describe your
culture and cultural background?

Demographic Profile (DP) 1 -How would
you describe your cultural identity (how
do you see yourself?)
DP 2 -How do you think culturally diverse
patients see you as a midwife?

culture, your own culture, values,
beliefs and prejudice and the
dynamics of difference and
relationships.

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164

RQ 2 – What cultural knowledge, skills and resources do midwives utilize to support the delivery of
culturally congruent care in midwifery practice?
IQ3 - How do you go about seeking and
obtaining cultural training, resources, or
tools to use in your midwifery practice?

Probes:
-Can you describe the type of training,
resources or tools?
-What training, resources or tools do you
need?
IQ5 - I would like to hear about your
experience of providing care to culturally
diverse patients. Can you share your
experience with a culturally diverse patient
new to the Canadian healthcare system in
BC?

Probes:
-What factors hindered or supported
cultural preferences from your point of
view?
-From the patient’s point of view?
-How was the situation addressed?

Cultural Knowledge: includes
basic knowledge of various
cultural groups and knowledge of
cultural groups served including
cultural issues.
Cultural Resources:
- Individual Resources
developed at the individual
level
- Organizational Resources
developed at the organizational
level
- Professional Resources
Regulatory bodies,
professional associations,
hospitals and health
authorities, research agencies,
Indigenous Bands/Nations
- Social resources Community

groups, communities
agencies, legal reports and
documents e.g. Truth &
Reconciliation Calls to
Action, Indigenous cultural
safety, cultural humility,
and anti-racism.

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RQ 3 – What are the cultural influences on midwifery care that inhibit or support the delivery of
culturally congruent care?

IQ5- I would like to hear about your
experience of providing care to culturally
diverse patients. Can you share your
experience with a culturally diverse
patient new to the Canadian healthcare
system in BC?
Probes:
-What factors hindered or supported
cultural preferences from your point of
view?
-From the patient’s point of view?
-How was the situation addressed?
IQ7- How does your culture influence
your practice?
Probes:
-Give an example
-How would you describe your culture
and cultural background?

Influences that inhibit or
support the delivery of
culturally congruent care.

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RQ 4 – How do midwives in BC integrate cultural considerations of care in practice?
IQ4- Can you describe in your own words
Formulation and
the way that you include cultural values,
implementation of birth plan in
beliefs and traditions into the birth plan
the Canadian healthcare system
during the prenatal, labour and postnatal
period?

Probes:
-What knowledge, supports, do you have
that you find useful?
-Are there resources that you wish you
had better access to?
-Are there things that get in the way or
make it hard for you to do what you want
to do?
IQ5- I would like to hear about your
experience of providing care to culturally
diverse patients. Can you share your
experience with a culturally diverse patient
new to the Canadian healthcare system in
BC?

Probes
-What factors hindered or supported
cultural preferences from your point of
view?
-From the patient’s point of view?
-How was the situation addressed?
IQ6- Do you have a similar story of someone
who is not new to Canada but has cultural
preferences that are not necessarily part of the
mainstream system?:

Appendix L: Tool for Demographic Profile Questions
In-text
Identifier
DF4/111/CS

DF5/RQ4

Description

Profile Question

Registered
midwives’
cultural
identity
Patient view
of Registered
midwives

4. How would you describe
your cultural identity (how
do you see yourself?)
5. How do you think
culturally diverse patients
see you as a midwife?

Interview
question
7

Colors for text

4, 5, 6

aqua

yellow

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Appendix M: Example of Coding
1

2
3

Project Title: Exploring Cultural Competence of Registered Midwives in British
Columbia, Canada

4
5

Ethics File No: Ref No : 10221

6
7
8
9
10
11
12
13
14
15

Interview Transcript

16

Date of Interview: 13-Aug-24
Interview Setting: Online via TRU Microsoft Teams
Interviewer: Kimberly
Interviewee: 038
(Start of Interview)

17

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19
20

Kimberly: To begin, I would like to hear about your midwifery practice? Solo or with
other
midwives?

24

038: Sure. So I practice in a rural and remote community[221/CK], somewhat
remote
and we're a practice of four midwives who work together and then we work actually.
So
we do all of our prenatal and postpartum clients on their own, but then for time on
call,
we actually share time on call with a couple of family doctors in our town, so yeah,
we
have a bit of a shared kind of practice in our community between GP and midwives.

25

Kimberly: Nice. So how did you choose this career?

26

038: I started out as a Registered Nurse and always was interested in perinatal care
and
so I did my nurse practitioner in midwifery[221/CK], so I did my Masters of
Nursing[221/CK] to become a Nurse midwife. And then just because of interest in
perinatal care and women's health in particular, and then I moved to Canada. I

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23

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28
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didn't
really anticipate being that practice owner, like when I became a midwife but being
in a
small community[111/CS] where we live, a really small community, that's just kind
of
the nature of being. There was no other practice for me to join. And so that's how I
became kind of a practice owner.

34

Kimberly: Nice, so what do you enjoy most about your practice?

35

038: I enjoy, I guess, two things. In the small town where we live and where I
practice, I
really enjoy practicing here. The work or the collegial environment is really good.
And I
feel really well supported by the community[221/CK] and kind of the infrastructure
in
the community into practice. And not just supportive, but also valued[221/CK. And
it

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31

36
37
38
39
40
41
42
43

1

168

just is a great pleasure to work in a small team who we all know each other well.
Because that's a real contrast to when I was working in the city before I came
here[111/CS1]. And you're one of many midwives, there's, you know, countless
nurses
that you don't interact with regularly, there's countless obstetricians and so working
in
a small town has been just so satisfying[111/CS].

Sense of work culture? Comparing small town to city

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Appendix N: Curriculum Vitae

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