NACCHO Aboriginal cultural safety in health care: New @AIHW monitoring framework assesses progress in achieving cultural safety in the health system for Indigenous Australians

” For the purpose of developing a monitoring framework cultural safety is defined with reference to the experience of the Indigenous health care consumer, of the care they are given, their ability to access services and to raise concerns.

Some of the essential features of cultural safety include an understanding of one’s culture; an acknowledgment of difference, and a requirement that caregivers are actively mindful and respectful of this difference.

The presence or absence of cultural safety is determined by the experience of the recipient of care and is not defined by the caregiver (AHMAC 2016).” 

AIHW Online Report HERE

Or Download Summary

Cultural safety in health care_ monitoring framework

1.Culturally respectful health care services

Cultural respect is achieved when the health system is a safe environment for Indigenous Australians, and where cultural differences are respected. This module reports on how health care is provided, and whether cultural respect is reflected in structures, policies and programs.

The 2017–18 Online Services Report data showed that among Indigenous primary health care providers:

  • 95% had a formal commitment to providing culturally safe health care
  • 84% had mechanisms to gain advice on cultural matters
  • over 70% of organisations  with a formal board had over half of Board members who were Indigenous
  • nearly 4 in 10 provided interpreter services; while around one third offered culturally appropriate services such as bush tucker, bush medicine and traditional healing.
  • 41% of health staff employed in these organisations were Indigenous
  • almost all (99%) provided cultural orientation for non-Indigenous staff.

National health workforce data showed that from 2013 to 2017:

  • the number of Aboriginal and Torres Strait Islander medical practitioners employed in Australia increased from 234 to 363
  • the number of Indigenous nurses and midwives employed in Australia increased from 2,434 to 3,540.

See more info PART 2 Below for modules 2 and 3

Part 1 Cultural Safety Background

The concept of cultural safety has been around for some time, with the notion originally defined and applied in the cultural context of New Zealand. It originated there in response to the harmful effects of colonisation and the ongoing legacy of colonisation on the health and healthcare of Maori people—in particular in mainstream health care services.

A commonly accepted definition of cultural safety from the Nursing Council of New Zealand (2002:7) is the ‘effective nursing or midwifery practice of a person or family from another culture, and is determined by that person or family… Unsafe cultural practice comprises any action which diminishes, demeans or disempowers the cultural identity and wellbeing of an individual.’

A distinctive feature of this definition of cultural safety is its emphasis on the provision of culturally safe health care services as defined by the end users of those services, notably, the Maori people of Aotearoa New Zealand, not by the (non-Maori) providers of care.

The National Collaboration Centre for Indigenous Health in Canada (2013) notes that culturally safe health care systems and environments are established by a continuum of building blocks:

Cultural awareness ⟹ Cultural sensitivity ⟹ Cultural competency ⟹ Cultural safety

The centre states that cultural safety ‘…requires practitioners to be aware of their own cultural values, beliefs, attitudes and outlooks that consciously or unconsciously affect their behaviours. Certain behaviours can intentionally or unintentionally cause clients to feel accepted and safe, or rejected and unsafe. Additionally cultural safety is a systemic outcome that requires organizations to review and reflect on their own policies, procedures, and practices in order to remove barriers to appropriate care.’

In Australia, there has been increasing recognition that improving cultural safety for Aboriginal and Torres Strait Islander health care users can improve access to, and the quality of health care. This means a health system where Indigenous cultural values, strengths and differences are respected; and racism and inequality is addressed.

There are difficulties in both defining and measuring generalised concepts such as cultural respect and cultural safety. They include lack of conceptual clarity and agreement on terms, the qualitative nature of the concepts, and the diversity of Indigenous Australians and their perceptions.

The Australian literature uses various definitions of cultural safety, and related concepts such as cultural respect and cultural competency, and what these mean in relation to the provision of health care.

For the purpose of developing a monitoring framework cultural safety is defined with reference to the experience of the Indigenous health care consumer, of the care they are given, their ability to access services and to raise concerns. Some of the essential features of cultural safety include an understanding of one’s culture; an acknowledgment of difference, and a requirement that caregivers are actively mindful and respectful of this difference. The presence or absence of cultural safety is determined by the experience of the recipient of care and is not defined by the caregiver (AHMAC 2016).

Two important aspects of culturally safe health care across the literature are, how it is provided and how it is experienced, and these form the basis for the monitoring framework (see AHMAC 2016; CATSINAM 2014; AIDA 2014; DHHS 2016; NACCHO 2011; Department of Health 2015).

How health care is provided

  • behaviour, attitude and culture of providers: respects and understands Indigenous culture and people
  • defined with reference to the provision of care, including governance structures, policies and practices

How health care is experienced  by Indigenous people

  • feeling safe, connected to culture and cultural identity is respected
  • can only be defined by those who receive health care

The importance of cultural respect and cultural safety is outlined in Australian government documents such as the Cultural Respect Framework 2016–26 for Aboriginal and Torres Strait Islander Health, and the National Aboriginal and Torres Strait Islander Health Plan 2013–23.

The Australian Commission on Safety and Quality in Healthcare (ACSQHC) also included six Aboriginal and Torres Strait Islander specific actions in the National Safety and Quality Health Service Standards to improve care for Aboriginal and Torres Strait Islander people in mainstream health services.

 Part 2 Summary

The cultural safety monitoring framework covers three domains: the first focusing on how health care services are provided, the second on Indigenous patients’ experience of health care, and the third on measures regarding access to health care.

Data are reported from a wide range of available national and state and territory level sources to provide a picture of cultural safety, though there are significant data gaps. Sources include both national administrative data collections and surveys of Indigenous health care users.

2.Patient experience of health care

The experiences of Indigenous health care users, including having their cultural identity respected, is critical for assessing cultural safety. Aspects of cultural safety include good communication, respectful treatment, empowerment in decision making and the inclusion of family members.

National survey data show that:

  • in 2014–15, an estimated 80% of Indigenous Australians who consulted a doctor/specialist in the last 12 months said that their doctor always/often listened carefully, while an estimated 85% said that their doctor always/often showed respect for what was said.
  • in 2012–13, an estimated 20% of Indigenous Australians reported being treated unfairly by health care staff in the last 12 months.

The differences in rates of Indigenous and non-Indigenous hospital patients who choose to leave prior to commencing or completing treatment are frequently used as indirect measures of cultural safety. Among:

  • emergency department presentations in 2015–16, around 8% of Indigenous patients and 5% of non-Indigenous patients took own leave or did not wait
  • hospitalisations in 2013–15, around 3% of Indigenous and 0.5% of non-Indigenous patients left against medical advice or were discharged at their own risk.

3.Access to health care services

Indigenous Australians experience poorer health than non-Indigenous Australians’, but they do not always have the same level of access to health services. This is due to a range of different reasons, including remoteness and affordability. Selected measures of access to health care services for Indigenous and non-Indigenous Australians are used to monitor disparities in access.

  • BreastScreen participation rates for the two year period 2016–2017 for Indigenous women were 27% compared with 34% for non-Indigenous women.
  • Indigenous Australians waited longer to be admitted for elective surgery in 2017–18 than non-Indigenous Australians (median waiting time of 48 days and 40 days, respectively).
  • In 2015, the potentially avoidable mortality rate for Indigenous Australians was over 3 times the rate for non-Indigenous Australians (345 and 105 per 100,000 respectively).

Data gaps

Monitoring cultural safety and cultural respect in the health system, and the impact it has on access to appropriate health care, are limited by a lack of national and state level data. This is particularly the case in relation to reporting on the policies and practices of mainstream health services, such as hospitals and primary health care services.

There is also limited data on the experiences of Indigenous health care users. Most jurisdictions undertake surveys about patients’ experiences in public hospitals, but there was  not a lot of available data on Indigenous patient experience. A high proportion of Indigenous Australians use mainstream health services, so further data developments in this area are required to allow for more comprehensive reporting across the health sector.

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