Date of Award


Publication Type

Master Thesis

Degree Name





advance care planning, advance directives, cultural safety, culturally safe advance care planning, end-of-life planning, internationally educated nurses


Kathryn Pfaff


Edward Cruz




ACP is recognized as a process that supports individuals in sharing their values, goals and preferences for future medical care. Engagement in ACP has been shown to be more influenced by culture than other factors. Uptake of ACP among ethnic minorities is low and failure to consider cultural preferences can cause moral harm for Canadian immigrants. Cultural safety aims to respect the values and beliefs embedded in one’s culture and allows individuals to experience a sense of security when making decisions. Existing literature on strategies to engage in culturally safe ACP is vague and poorly explored. Nurses play a key role in facilitating ACP discussions in their practice. In particular, internationally educated nurses (IENs) are uniquely positioned to share their home country and Canadian experiences and to speak about practices that can maintain cultural safety in the ACP process. An interpretive descriptive approach was applied to understand how IENs might contribute to facilitating culturally safe ACP and subsequently inform nursing practice and ACP policy. IENs reported that in their home countries, ACP was poorly carried out and not valued. In Ontario, IENs expressed that ACP was often focused on determining goals of care status. IENs recognized that ACP went beyond goals of care discussions as they sought to engage individuals and families in culturally safe ACP discussions. The analysis revealed that IENs engaged in various practices that were categorized under three key themes: cultural humility, a cautious open approach, and empowering clients. Participants described how culturally safe ACP practices could be supported in changes to nursing education, practice, and policy. Research, theory, and policy development are needed to advance the concept of culturally safe ACP. Best practices for culturally safe ACP and organizational supports are needed to assist nurses in delivering culturally safe ACP.