Most cultural training in health care asks the practitioner to learn about other people: their foods, their holidays, their beliefs about illness. An idea that grew out of New Zealand nursing schools in the late 1980s turned that around. Under it, whether care was culturally safe isn’t settled by how much the nurse knows. The Nursing Council of New Zealand says it is determined by the person, or the family, receiving the care.
That shift, from what the practitioner knows to what the patient experiences, is the most useful single idea available to anyone thinking about respect in health practice. It applies to a hospital ward. It applies just as well to a wellness practitioner offering a ceremony or technique drawn from someone else’s tradition, which is where the stakes have sometimes been fatal.
This article covers where cultural safety came from and how it differs from cultural competence, what the federal standards for US health organizations say after their June 2025 revision, what people from source communities have said about outsiders leading their practices, and what the trial over the 2009 deaths in an imitation sweat lodge in Arizona did and did not decide. Medicaid payment for traditional healing, federal law on Indigenous plant knowledge and the international bodies that define traditional medicine each get separate treatment elsewhere in this library.
Where cultural safety came from
The concept has named authors, and its own regulator tells the story.
The Nursing Council of New Zealand’s guidance on cultural safety, first published in March 2005 and last amended in September 2025, traces the idea to the shared experiences of Māori nursing students and nursing teachers in the late 1980s. Māori nurse leaders and educators, led by Dr. Irihapeti Ramsden, developed the recommendations that followed. In 1990 the Council changed its nursing standards to build cultural safety into how curricula were assessed. Ramsden wrote the first guidelines for nursing schools in 1991, and the Council formally adopted them in 1992 under a Māori name, Kawa Whakaruruhau.
The Council uses that term for care that respects and upholds the cultural identity, values and rights of Māori. Cultural safety is the broader idea, extending the same logic to anyone receiving care from someone of another culture.
Ramsden co-wrote one of the earliest published accounts. In a 1996 paper in the International Journal for Quality in Health Care, she and Papps, of the nursing and midwifery department at Otago Polytechnic in Dunedin, wrote that cultural safety arose from New Zealand’s colonial context. Māori nurses prompted it, responding to the poor health of Māori and to Māori insistence that the delivery of services change profoundly. Nursing and midwifery organizations, they wrote, backed the initiative as something true to nursing and to the country. Cultural safety became a requirement for nursing and midwifery courses in 1992. The paper is frank that the change was controversial: it drew heavy national media coverage, and the Council’s own role was questioned.
Sources differ slightly on dates. A 2019 review by researchers at Te Kupenga Hauora Māori at the University of Auckland says the term was first proposed in the 1990s. This article follows the Council’s own timeline, which places the origins in the late 1980s, because the Council adopted the standard and documents its history.
Competence asks what you know; safety asks who decides
The Council draws the distinctions carefully, and they’re worth keeping straight. Cultural awareness, in its account, is a first step: recognizing that difference exists. Cultural sensitivity goes further, accepting that difference is legitimate. Cultural safety extends beyond both. And cultural competence, the term most familiar in the United States, may help in delivering care, the Council says, but isn’t enough by itself to improve health outcomes.
Its definition of the failure is just as specific. Unsafe cultural practice, in the Council’s terms, is any action that diminishes, demeans or disempowers a person’s cultural identity and wellbeing.
The 2019 review explains why the difference matters. Its authors, led by Elana Curtis at Te Kupenga Hauora Māori at the University of Auckland, originally prepared the work to inform the Medical Council of New Zealand. They identify power as the key difference between the two concepts. Cultural safety, they write, rejects the idea that health providers should focus on learning the customs of different ethnic groups. It moves the focus to the culture of the clinician and the clinical setting, and lets the patient judge whether an encounter was safe.
The review drew on 59 articles published between 1989 and 2018, from the United States, Canada, Australia, New Zealand, Taiwan and Sweden. It notes that some jurisdictions have already written cultural competency into professional licensing laws and accreditation standards, which is why the definition matters: whatever a regulator adopts becomes what practitioners are trained and measured against. Its conclusion is that organizations and authorities should be held accountable for care that patients and their communities judge to be safe.
The authors also name the risk in the familiar approach. A checklist version of competence, they argue, can leave practitioners feeling more capable than they are. Learning facts about a group can turn into stereotyping the individual in front of you.
Here is what that looks like in practice, as an illustration rather than a finding. A competence-minded clinician who has read that a patient’s community uses a particular herbal tea may ask about the tea. A safety-minded clinician asks what the patient does to stay well, listens, and changes course if the patient says something about the visit felt wrong. The first approach tests the clinician’s knowledge. The second gives the patient the deciding vote.
The US standard, after its June 2025 revision
The closest American counterpart is a set of federal standards aimed at institutions rather than individuals. The CLAS Standards, short for culturally and linguistically appropriate services, are federal benchmarks published by the Department of Health and Human Services through its Think Cultural Health program. There are 15. A Principal Standard sits first, followed by three groups covering governance and workforce, communication and language assistance, and engagement, improvement and accountability.
The standards were revised in June 2025, and the wording changed in ways that matter to anyone quoting them. The current document says the standards are “intended to promote health, improve quality and help eliminate health care disparities,” and frames them as a blueprint for health and health care organizations. The version HHS labeled the 2013 standards said they were intended to advance health equity. That phrase is gone.
The Principal Standard changed too. It still asks organizations to provide effective, understandable and respectful care, responsive to people’s cultural beliefs and practices around health, their languages, their health literacy and their other communication needs. But the 2013 version included the word equitable, and spoke of diverse cultural beliefs and preferred languages. A search of the June 2025 document finds none of those words, and no form of equity anywhere. One word in the current Standard 3 is worth noticing: it asks organizations to build a workforce that responds to the digital, cultural and language needs of the population.
Three cautions apply. The revised document carries no date or office name inside it; the June 2025 date comes from its file name on the HHS site. Neither the current nor the 2013 document read for this article says whether the standards are voluntary or required. And nothing read applies them to individual practitioners, let alone to an unlicensed wellness business. The practical, front-desk version of these standards, including free interpreters and what to ask for, is the focus of the library’s guide to care that fits your language and culture.
The data-collection side of CLAS can surface problems an individual clinician would never see. A 2025 study of a free bedside integrative health service at NYU Langone’s Manhattan hospital, covering September 2022 to February 2024, found that Asian American patients and patients who did not prefer English had markedly lower odds of being referred than other patients. The authors raised the possibility of implicit bias among the clinicians placing referrals. No single nurse would notice that pattern. Only counting by language and background reveals it.
Notice the difference in vantage point. CLAS is written from the organization’s side: what a health system should build. Cultural safety is written from the patient’s side: who decides whether it worked. A clinic can meet every structural standard and still fail the second test in a single conversation.
The standards still give you something to ask about. Whether a clinic records the languages its patients speak, whether it checks its own numbers for gaps like the one at NYU, and whether its complaint process works for someone who struggled to understand the visit are all fair questions under a federal benchmark, whatever its legal force.
When the practitioner is the outsider
Cultural safety was built for nurses caring for Māori patients. The same logic reaches a situation the American wellness market creates constantly: a practitioner from outside a tradition, offering its practices for a fee. If safety is judged by the people on the receiving end, then the communities whose practices are being offered have standing to say what respect looks like.
They have said so, and not with one voice.
Vi Waln, a Sicangu Lakota writer, enrolled member of the Rosebud Sioux Tribe and editor of the Lakota Country Times, wrote a column, posted online on June 6, 2011, while the Arizona trial described below was under way. She argued that the lodge at the center of that case was an imitation, not the Lakota ceremony known as the inikaga, and wrote: “An authentic inikaga is not an endurance contest.” She urged Lakota spiritual leaders to limit participation in their ceremonies to tribal members. She also quoted a 1993 Lakota declaration warning that some of their own people were exploiting Lakota spiritual ways for selfish gain. Hers is one editor’s column, not a tribal government’s resolution, and should be read that way.
A very different request comes from the Hindu American Foundation. Its Take Back Yoga campaign, described by NPR in April 2012, asked for acknowledgment that yoga has Hindu philosophical roots. A senior director at the foundation, Sheetal Shah, described yoga as a lifestyle and a philosophy, not just poses. The campaign presented yoga as open to everyone and did not ask non-Hindus to stop practicing. The same report gave other views. The journalist William Broad argued that modern yoga was largely reinvented in the 1920s and 1930s, and the teacher Alison West cautioned against overstressing its Hindu origins. The foundation’s position is its own, not settled history.
Put those side by side and the variety is the point. One voice asks for limits on who takes part. Another asks for credit and context while welcoming everyone. Statements about white sage gathered in the library’s article on Indigenous plant knowledge show the same range, from no sale of medicines at all to certification and outreach. Treating any of these as what all Native people or all Hindus think would repeat the stereotyping that cultural safety was meant to end.
Sedona, 2009: what the court decided, and what it didn’t
The deaths of three participants at a commercial sweat lodge near Sedona, Arizona, in October 2009, and the operator’s conviction for negligent homicide, are told in a separate library article alongside the federal law on misrepresenting goods as Native-made and a Lakota keeper’s proclamation on ceremonies. This section adds what that account leaves out. It draws on Associated Press and local newspaper reports; the court docket itself was not read, so details carry that limit.
The operator, a self-help author who was not Native, ran the ceremony at the close of a five-day seminar that cost $10,000 a person, according to local reporting, which also said he had warned participants that his lodge was more intense than others. The AP account says he promised it would help them break through whatever was holding them back. By the end of the roughly two-hour ceremony, the AP reported, some participants were vomiting, struggling to breathe or lying motionless.
At trial, prosecutors called more than 30 witnesses and argued that the operator knew the risks, failed to provide adequate safety measures, raised the heat to dangerous levels and ignored pleas for help from people in distress. Some witnesses described him as a coach who never forced anyone to stay. The defense suggested toxins on the tarps might have contributed, a theory the jurors did not accept.
On November 18, 2011, Judge Warren Darrow sentenced him to three two-year prison terms, to run at the same time, and ordered more than $57,000 in restitution. Prosecutors had sought nine years. The judge said probation was unwarranted. In September 2013, the Arizona Court of Appeals allowed him to drop his appeal and dismissed the state’s cross-appeal, leaving the convictions in place.
Now the limits. The court made no ruling on cultural appropriation. The Associated Press described a sweat lodge as a ceremony typically used by American Indians to cleanse the body, but the case was about whether a seminar leader’s conduct negligently caused three deaths. The appropriation argument was made in Native media and commentary, not in the verdict, and the two should not be merged.
One observation is this article’s own, not the court’s. The feature prosecutors focused on, a ceremony run as a test of how much heat people could stand, is the same feature Waln singled out that June as the mark of an imitation. The safety failure and the cultural failure point at the same thing.
Cultural safety offers a way to see why. It asks practitioners to examine their own culture rather than study someone else’s. In a paid seminar, the culture in the room was the seller’s: a premium price, a promise of breakthrough, and intensity presented as the product. For an outsider bringing a ceremony to market, that culture, more than the borrowed form, is the thing to examine.
Questions worth asking a practitioner from outside the tradition
These are your own checks, built from the ideas above. A respectful practitioner will answer them without irritation.
- Who taught you, and does the community this comes from recognize that teaching? A specific name and a specific relationship mean more than the words ancient or traditional.
- What have you changed from the original practice, and why? Changes for a paying audience are common. Hiding them isn’t a good sign.
- What happens if someone becomes unwell? For anything involving heat, fasting, intense breathing or long sessions, there should be a plan and someone watching.
- Can I stop or leave at any point, and how will you respond? Under cultural safety the person receiving care decides whether it is safe. A practitioner who treats leaving as failure has the logic backward.
- At a clinic: how do you ask about the practices I use at home, and who handles a complaint? You’re asking whether the organization’s standards reach the exam room.
When getting help can’t wait
Heat ceremonies, sweat lodges and group sauna events are where respect and physical safety meet most directly. The Centers for Disease Control and Prevention, in heat illness guidance last reviewed in March 2026, lists signs of heat stroke that include confusion or altered mental status, slurred speech, loss of consciousness, seizures and very high body temperature. It says to call 911 for emergency care. Earlier signs of heat exhaustion include headache, nausea, dizziness, weakness, irritability, thirst and heavy sweating.
The distress described in Sedona, people vomiting, fighting for breath and collapsing, overlaps that list. Leaving a hot enclosure, and calling for help for someone else, needs nobody’s permission. If you have a chronic health condition or take regular medication, ask your clinician whether prolonged intense heat is safe for you before taking part.
The Takeaway
Respect in health practice is measured by the person receiving care, not by the practitioner’s training or intentions. That is the core of cultural safety, a standard Māori nurses created and New Zealand’s nursing regulator adopted. It is also the most practical test you can apply anywhere: whether you were free to say what felt wrong, and whether anyone changed course when you did.
Keep exploring: tell your doctor about acupuncture.
Sources
- Nursing Council of New Zealand. “Te Tiriti o Waitangi, Maori Health, Kawa Whakaruruhau and Cultural Safety: Guidance for Nursing Education and Practice (first published March 2005; last amended September 2025).” nursingcouncil.org.nz
- International Journal for Quality in Health Care. “Papps E, Ramsden I. "Cultural safety in nursing: the New Zealand experience." Int J Qual Health Care, 1996. PubMed. DOI: 10.1093/intqhc/8.5.491.” pubmed.ncbi.nlm.nih.gov
- International Journal for Equity in Health. “Curtis E, Jones R, Tipene-Leach D, Walker C, Loring B, Paine SJ, Reid P. "Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition." Int J Equity Health, 2019. PubMed. DOI: 10.1186/s12939-019-1082-3.” pubmed.ncbi.nlm.nih.gov
- U.S. Department of Health and Human Services, Think Cultural Health. “National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (revised June 2025; date from file name).” thinkculturalhealth.hhs.gov
- U.S. Department of Health and Human Services, Think Cultural Health. “National CLAS Standards fact sheet (labeled National CLAS Standards 2013).” cccdpcr.thinkculturalhealth.hhs.gov
- Global Advances in Integrative Medicine and Health. “Millon EM, Shang A, DeMarco KA. "Characteristics of Hospitalized Patients Referred for Complementary and Integrative Health Services at a Large Metropolitan Academic Medical Center." Glob Adv Integr Med Health, 2025. PubMed. DOI: 10.1177/27536130251388991.” pubmed.ncbi.nlm.nih.gov
- Indianz.com. “Vi Waln: Spiritual legacy being stolen from under our noses (column posted June 6, 2011).” indianz.com
- NPR. “Report on the Hindu American Foundation's Take Back Yoga campaign (April 11, 2012).” npr.org
- Associated Press via MPR News. “Felicia Fonseca, sentencing report on James Arthur Ray (November 18, 2011).” mprnews.org
- Associated Press via MPR News. “Report that the Arizona sweat lodge convictions stand after the appeal was dropped (September 9, 2013).” mprnews.org
- JournalAZ (Larson Newspapers). “Mark Lineberger, verdict report on James Arthur Ray (June 27, 2011).” journalaz.com
- Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. “Heat-related Illnesses (last reviewed March 3, 2026).” cdc.gov