” 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).”
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 ⟹
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 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).
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.
“Providing culturally safe services is critical to Closing the Gap in health equality. We welcome CATSINaM’s initiative to share experiences and to learn from Aboriginal and Torres Strait Islanders to strengthen the capacity of health professionals to deliver culturally safe services for our people.
This training will not only support all nurses and midwives to meet the standards of their Codes of Practice, it will also embed cultural safety in the health system, improving healthcare and helping Close the Gap in Aboriginal and Torres Strait Islander health outcomes,”
CATSINaM CEO Janine Mohamed said the funding would help realise a project the organisation had been working on with the Government and other partners for the past five years
Picture above : The Minister with Janine Mohamed of CATSINaM and Annie Butler of ANMF
Please note : Melanie Robinson has been appointed as the as the new CATSINAM CEO as from 4 th February See Part 2 below
The Federal Government will provide $350,000 to produce an Australian-first online cultural safety training course for nurses and midwives delivering frontline care to Aboriginal and Torres Strait Islander people.
Indigenous Health Minister Ken Wyatt AM made the announcement at a national roundtable in Sydney on developing and rapidly expanding the Aboriginal health workforce.
The Minister with Aboriginal Elder Aunty Beryl and some of the staff and students from the National Centre for Indigenous Excellence @theNCIE in Redfern who prepared the wonderful morning tea and BBQ lunch at the Indigenous HealthWorkforce Roundtable
“Everyone using health services in Australia should feel valued and respected throughout their consultation and aftercare,” Minister Wyatt said.
“Our Government, through the Indigenous Australians’ Health Program, will fund the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives to develop the online cultural safety training course this year.
“The innovative use of established web technology will enable all nurses and midwives to learn about culturally safe care where they live and work, and at a time which suits them.”
The Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) is the peak body representing Aboriginal and Torres Strait Islander nursing and midwifery professionals across Australia.
“The online training program will be adapted for Australia from a successful model developed by Indigenous leaders in Canada,” said Minister Wyatt.
The inclusion of cultural safety as one of the Codes of Professional Standards for nurses and midwives is driving an increase in demand for cultural safety training.
“The importance of cultural safety training is recognised across the health sector,” Minister Wyatt said.
“There is also potential for this initiative to build the cultural understanding of health professions beyond the fields of nursing and midwifery.
“The training will align with the objectives of the Cultural Respect Framework 2016-2026 for Aboriginal and Torres Strait Islander Health to include local culture in the design, delivery and evaluation of services.”
Provision of cultural safety training also supports strategies under the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013-2023, to prevent and address systemic racism and discrimination in the health system.
The Liberal National Government is providing $3.9 billion to improve the health of Aboriginal and Torres Strait Islander people over the next four years.
Part 2 Melanie Robinson has been appointed as the as the new CATSINAM CEO as from 4 th February
The Congress of Aboriginal and Torres Strait Nurses and Midwives (CATSINaM), the national peak body for Aboriginal and Torres Strait Islander Nurses and Midwives, today welcomes the appointment of Melanie Robinson as the new CEO. Ms Robinson, a nurse who has been a director of CATSINaM for three years, has worked clinically, in nurse training and policy development, most recently holding a senior position with the Western Australian Department of Health (see bio below).
She will move from Perth to Canberra to take up her new position with CATSINaM on 4 February 2019.
CATSINaM acting president, Marni Tuala, said that Melanie Robinson is a fantastic addition to the CATSINaM team given her unswerving commitment to Aboriginal and Torres Strait Islander health as well as nurse and midwife employment issues, and her profile within the national Aboriginal and Torres Strait Islander healthcare community
. “Melanie brings valuable experience and a fresh perspective to the role of CEO,” Ms Tuala said. “Melanie knows the benefits and rewards of working as a nurse and has a deep understanding of the issues that Aboriginal and Torres Strait Islander nurses and midwives face on a daily basis.” Ms Robinson said it is an honour to be a part of such a vibrant and important organisation that advocates for Aboriginal and Torres Strait Islander nurses and midwives.
Her priorities would include growing the number of Aboriginal and Torres Strait Islander nurses and midwives across Australia, and ensuring the workforce was strongly supported.
“It’s important that we look at what is working – within the universities, the vocational training sector and in terms of employment pathways – and translate these lessons more widely,” Ms Robinson said. “I am looking forward to advocating for our members, engaging with national policy development, and building strong partnerships across the government and non-government sectors, and working with the other peak bodies
. “I am also keen to continue the work of raising CATSINaM’s profile, at local, national and international levels.”
As a passionate advocate for CATSINaM, Ms Robinson said the organisation had been critical for her own journey of professional development and she wanted to ensure that others had similar opportunities.
“When I discovered CATSINaM, it opened up this whole other world as I met others with a shared history and experiences,” she said. “I will be working hard to ensure that CATSINaM offers those same opportunities to others that it has brought me.”
Ms Robinson said she hoped that the wide-ranging experience she had gained over the last 30 years would be useful for CATSINaM and its members. She commended an Aboriginal Leadership and Excellence Development program that she undertook in WA for building her confidence to take on senior roles.
Acting CATSINaM president Marni Tuala said the CATSINaM Board was keen to acknowledge the legacy of the outgoing CEO, Janine Mohamed. “CATSINaM recognises and commends the incredible achievements made by the outgoing CEO, Janine Mohamed. Her contributions during her six years in the role will not be forgotten, especially in the advocacy and implementation of cultural safety across healthcare.
Janine will continue to be a valuable member of the CATSINaM community,” Ms Tuala said.
Media Contact: Sarah Stewart: 02 62625761/ Melanie is available for interviews and profile articles.
Please contact Sarah Stewart for full information
Bio – Melanie Robinson I was born in Derby in the Kimberley region of Western Australia and grew up on the Gibb River Road in Ngallagunda community.
When I was 8 years old we moved into Derby for school and after that I went to boarding school at Stella Maris College.
I finished year 12 in 1989 and then in 1990 I commenced a Bachelor of Science (Nursing) at Curtin University completing the course in December 1993.
As a graduate I move back to Derby and completed 18 months in Derby Hospital working in paediatrics, general medical and emergency department. During this time I worked in Fitzroy Crossing hospital and the aged care facility in Derby called Numbla Nunga.
In 1996 I travelled overseas and lived in London for 6 months and then I returned to Perth and began working at Royal Perth Hospital a tertiary service where I worked for the next 2.5 years in aged care, acute medical and the intensive care unit.
In 1998 I travelled to Dublin and lived there for a year with a friend and her family, working in a local aged care unit. In 1998 I returned to Perth and commenced work in Princess Margaret Hospital where I worked in oncology, hematology and Intensive Care for the next 9.5 years.
I loved working with children and their families, which is a very specialised area and often extremely challenging.
In 2008 I decided to take a position as a nurse educator at Marr Mooditj Training and mentored and taught a number of Aboriginal students in enrolled nursing and Aboriginal Health Worker Programs. I loved this work and really enjoyed learning more about Noongar people and getting to know the local Aboriginal community.
In 2013 I took on a new position as a Senior Policy Officer in the Western Australian Department of Health.
In 2015 I managed to gain a promotion into a Senior Development Officer role and I completed a Masters in Nursing Research at the University of Notre Dame Australia in June 2018.
In 2018 for 6 months I acted as the Director Aboriginal Health in the Child and Adolescent Health Service in Western Australia. In the future I plan to return to nursing and enrol in the Masters in Midwifery Practice to gain the skills as a midwife.
” Cultural safety challenges nurses and midwives to work in partnership with people and communities but acknowledges that the system is weighted towards the interests of those who work in the system. We think we give the same care to everyone, but everyone experiences our care differently.
Once we understand ourselves and our health system as having a culture that privileges some people over others – whether we are conscious of it or not – we can get on with the real work of implementing better healthcareexperiences for Aboriginal and Torres Strait Islander peoples and other marginalised groups.’
Dr Ruth De Souza Busting the 5 Myths of cultural safety See Part 2 Below
And those crazy claims weren’t just on Seven. The trusty Daily Mail had them the day before:
Racist to its core. Outrage as nurses are subject to a new code where they must announce their ‘white privilege’ before treating Aboriginal and Torres Strait Islander patients
— Daily Mail, 21 March, 2018
Is it April Fool’s Day, I hear you ask? No, that’s still a week away.
So where did it come from?
Take a bow Peta Credlin, Tony Abbott’s former chief of staff, who told her Sky News viewers on Wednesday it was a story she “almost can’t believe”.
At least she got that bit right. She then went on to ask her guest:
PETA CREDLIN: Please tell me I’m wrong. As I understand it, this new code of conduct for nurses in Queensland requires obviously white nurses to announce they’ve got white privilege before they can look after patients of an Indigenous or Torres Strait Islander background. Am I right there?
— Sky News, Credlin, 21 March, 2018
And back came the answer from Graeme Haycroft of Queensland nurses’ association the NPAQ:
GRAEME HAYCROFT: Yes, you are, except that it’s not just Queensland, Peta, it’s all of Australia, there’s 350,000 nurses and midwives Australia-wide and they’re all now subject to this new code.
— Sky News, Credlin, 21 March, 2018
So, is the story true? Well no. Although there is some basis to it.
There IS a new code for nurses and midwives, which came into effect this month, and it does talk about Indigenous patients, and the glossary does say this about white privilege:
GRAEME HAYCROFT: In relation to Aboriginal and Torres Strait Islander health, cultural safety provides a decolonising model of practice based on dialogue, communication, power sharing and negotiation, and the acknowledgement of white privilege.
— Sky News, Credlin, 21 March, 2018
Now you might think that is pretty barmy stuff. But, the glossary is not the code that nurses must adhere to.
And nurses are not required, forced or even encouraged to announce their white privilege to patients before treating them, or indeed at all.
Yet that crazy claim has been gathering strength for weeks. Ever since Cory Bernardi first made it in January in his, quote, “Weekly Dose of Common Sense”, where he dubbed it “medical Marxism” and claimed the code says:
Nurses must acknowledge white privilege and voice this acknowledgment if asked …
— Senator Cory Bernardi’s Weekly Dose of Common Sense, 31 January, 2018
True to form, The Daily Telegraph was first to seize on the story. Then, a few weeks later the Cairns Post cranked it up.
And last week the Daily Mail and News.com.au followed the Credlin interview by revving it up again.
At which point Andrew Bolt and Chris Smith joined the fun:
ANDREW BOLT: What about if they’re just within seconds of dying and the nurse has to fling themselves into action, but they have to stop, before, while they just announce their white privilege, oh too late.
CHRIS SMITH: Yeah.
ANDREW BOLT: Gone.
CHRIS SMITH : Please keep your heart beating for one more beat, because sir I need to talk to you about my white privilege.
— 2GB, The Chris Smith Show, 22 March, 2018
So, who is driving all this outrage?
Answer: Credlin’s interviewee, Graeme Haycroft, founder of the breakaway union, the Nurses Professional Association of Queensland, which represents around 2500 – yes, 2500 – of Australia’s 390,000 nurses and midwives.
Now Haycroft is not a nurse but a labour hire millionaire, who’s made his fortune busting unions. He’s also a former bigwig in the LNP, and a member of the fiercely anti-union HR Nicholls Society.
And he’s been spreading fear about the code to anyone who’ll listen, like the inimitable John Mackenzie, or Macca, on Cairns’ 4CA:
JOHN MACKENZIE: … When this issue emerged, everyone thought it was a practical joke. But it’s far from a practical joke, isn’t it?
GRAEME HAYCROFT: Well, yes, it’s worse than that. It’s an insidious form of racism and … it’s going to end up with a form of apartheid in the health system.
— Classic Hits 4CA, Mornings with John MacKenzie, 7 March, 2018
And a couple of weeks before that, Graeme Haycroft was getting 2GB’s Michael McLaren in Sydney equally riled up:
MICHAEL MCLAREN: This all sounds ridiculous to me. What the hell is cultural safety? No one’s ever heard of it.
— 2GB, Overnight with Michael McLaren, 13 March, 2018
So, what is cultural safety? Well, according to that new code from the Nursing and Midwifery Board of Australia:
Rather than saying ‘I provide the same care to everyone regardless of difference,’ cultural safety means providing care that takes into account Aboriginal and/or Torres Strait Islander peoples’ needs.
— Nursing & Midwifery Board of Australia code of conduct for nurses and code of conduct for midwives, March, 2018
Doesn’t sound too bad, you might think. But Haycroft – who’s using the issue to rally support for his union – claims the code will see nurses lose their jobs. And here is how:
GRAEME HAYCROFT: If you’ve got an Aboriginal or Indigenous patient and they don’t like the bedside manner of the nurse because the nurse is not acknowledging her white privilege, if she happens to be white, then a complaint can be lodged and there’s no defence.
— 2GB, Overnight with Michael McLaren, 13 March, 2018
So, is that true? Well, no again, at least according to the Nursing and Midwifery Board of Australia, who drew up the code:
MEDIA WATCH: Are nurses encouraged to announce their ‘white privilege’ before treating indigenous patients?
MEDIA WATCH: Is there any requirement to acknowledge or announce ‘white privilege’ before treating a patient?
MEDIA WATCH: Can a nurse be sacked for NOT declaring or addressing their ‘white privilege’ to a patient?
NMBA: No. The recent criticisms from Mr Haycroft are based on completely untrue statements.
— Nursing & Midwifery Board of Australia, 23 March, 2018
Graeme Haycroft told Media Watch he stands by his claims, and no doubt he’ll be encouraged to keep on repeating them by conservative commentators who’d love to believe they’re true.
But they are not.
And he should not be allowed to make the claims unchallenged.
Dr Ruth De Souza is a nurse, writer, speaker and researcher with a passionate interest in culture and health. She has combined her academic career with governance and community involvement, talking and writing in popular and scholarly venues about mental health, maternal mental health, race, ethnicity, biculturalism, multiculturalism, settlement, refugee resettlement, and cultural safety.
The Council of Deans of Nursing and Midwifery ANZ acknowledge Aboriginal & Torres Strait Islander people as the First Nations people of Australia. The Council supports the development and implementation of cultural safety in education programs, practice, and research activities for nurses and midwives. It also recognises that the origins and context informing the development of cultural safety arise from different historical, political, economic social and ideological positions in Australia and New Zealand and therefore this will be acknowledged separately
However, this explicitly anti-racist and equity informed strategy has not gone down well with The Nurses Professional Association of Queensland Inc (NPAQ). Run by union-buster Graeme Haycroft who calls the Codes ‘racist’, the association brands itself as a non party political alternative to existing unions. Haycroft has garnered a deluge of support (despite not being political) and claims NPAQ members were not consulted and 50 per cent of NPAQ members are opposed to the Codes. Interviewed by Sky News host Peta Credlin, supporters likeAndrew Bolt have jumped into the fray with headlines screaming: Nurses forced to announce ‘white privilege’ is new racism. The hyperbole has been astounding:
What if… they’re within seconds of dying and the nurse has to fling themselves into action but they have to stop while they just announce their white privilege?
These codes were the subject of lengthy consultations with the professions of nursing and midwifery and other stakeholders including community representatives. This review was comprehensive and evidenced-based. Our union and our national body the Australian Nursing Midwifery Federation (ANMF) were active participants in these consultations.
The codes, written by nurses and midwives for nurses and midwives, seek to ensure the individual needs and backgrounds of each patient are taken into account during treatment.
There’s no doubt cultural factors, including how a patient feels while within the health system, can impact wellbeing. For example, culture and background often determine how a patient would prefer to give birth or pass away.
Every day, nurses and midwives consider a range of complex factors, including a patient’s background and culture to determine the best treatment. These codes simply articulate what is required to support safe nursing and midwifery practice for all.
As CEO of CATSINaM Janine Mohamed observes in a blog for Indigenous X “Australia is playing a game of ‘catch up’”. Indeed, cultural safety is an approach developed by indigenous Māori nurses that is embedded in the undergraduate national nursing curriculum, and broadly applied across marginalised groups in New Zealand. The Nursing Council of New Zealand introduced the concept into nursing and midwifery curricula in 1992, developing the expectation that nurses practise in a ‘culturally safe’ manner. It wasn’t without resistance, however.
As a nurse, academic and researcher, cultural safety has informed my professional practice. I completed a PhD which attempted to extend the theory and practice of cultural safety to both critique nursing’s Anglo-European knowledge base, and to extend the discipline’s intellectual and political mandate with the aim of providing effective support to diverse groups of mothers (Migrant Maternity).
Cultural safety is creating racism, not eliminating it. It’s political correctness gone mad!
Correction: Race is a proven determinant of health. The Nursing and Midwifery Codes of Conduct acknowledge racism and attempt to reduce its impact on health.
Australia is a white settler society like the United States, Canada and New Zealand. In such settler societies, colonisation and racism have had devastating effects on Indigenous health and wellbeing. These include: the theft of land and economic resources; the deliberate marginalisation and erasure of cultural beliefs, practices and language; and the forced imposition of British models of health over systems of healing that had been in Australia for millennia.
Along with the systematic destruction of these basic tools for wellbeing, interpersonal racism has also contributed to a reduction in access to health promoting resources for Indigenous communities. Cultural safety was developed and led by Indigenous nurses in New Zealand to mitigate the harms of colonisation and improve health care quality and outcomes for Māori, and this has been extended by nurses in Australia, Canada and the US.
Evidence demonstrates that health system adaptations informed by a cultural safety approach have benefits for the broader community. For example, in New Zealand, the request by Māori to have family involved in care (whānau support) have led to a more family-oriented health care system for everyone.
I’m white but I’ve had a hard life, who is to say that I am privileged? Why am I being called racist for being white? That’s racist! I am a nurse, I’ve been abused, I am not privileged. I fought hard for everything I have and have achieved today.
Correction: Whiteness and white privilege refers to a system, they are not an insult.
Scholar Aileen Moreton-Robinson points out that British invasion and colonisation institutionalised whiteness into every aspect of law and policy in Australia. One of the first actions of the newly formed Australian nation state in 1901 was to pass the Immigration Restriction Act restricting the entry of non-white people.
The White Australia policy ended in 1962, when some of our lawmakers today were adults. Unsurprisingly, politicians have reflected these assumptions as they have demonised successive groups of migrants and refugees.
This culture of whiteness confers dominance and privilege to those who are located as white, but is largely invisible to them, and very visible to those who are not white. Being white in a settler colony like Australia means that you can move through daily life in a world that has been designed by people who are white for people who are white.
Even accounting for class and poverty, people who are white experience privileges that are not available to people of colour. White people can’t actually be systematically oppressed on the basis of their race by Indigenous people or people of colour, because the colonial systems of governance are still in force.
As the comedian Aamer Rahman points out, so called “reverse racism” would only exist under circumstances where white people had been intergenerationally marginalised from the social and economic resources of the nation on the basis of their race. The way Graeme Haycroft from the Nurses Professional Association of Queensland Inc attempts to create equivalence between the inconvenience of having to think differently about health with generations of dispossession is farcical and insulting.
Why can’t we treat everyone with respect? Dividing people into categories of oppressors and victims isn’t helpful. I respect each patient and their diversity as I respect all the nurses I work with and their cultural diversity.
Correction: No matter what individuals believe, entering the health system is not always a safe experience for cultural minorities. Providing tailored care where possible helps the health system work for everyone.
One size does not fit all. It’s not helpful to treat everybody the same or to say that one does not see colour. How one shows respect varies from one person to the next. Some things work for some people, while others don’t.
Many nurses and midwives already tailor health care to people’s bodies, genders, class and sexuality. For example, the grumpy old entitled man is a well-known “type” of patient that nurses have dealt with for generations, disrupting their own routines and responding to patient demands in order to get them to accept the care required.
Cultural safety promotes an understanding of the culture of health and asks nurses and midwives to be learn to be more responsive to the needs of the patient generally, and this only benefits patients.
Cultural safety asks caregivers to challenge biases and implicit assumptions in order to improve healthcare experiences for Aboriginal and Torres Strait Islander peoples. In the codes, cultural safety also applies to any person or group of people who may differ from the nurse/midwife due to race, disability, socioeconomic status, age, gender, sexuality, ethnicity, migrant/refugee status, religious belief or political beliefs.
In other words, where “business as usual” is designed for white people, cultural safety is for everyone.
Why is cultural safety being regarded in the new Codes of Conduct as equally important to the patient as clinical safety? Doesn’t that devalue clinical care?
Correction: Cultural safety enhances clinical safety.
People are more likely to use health services that are appropriate, accessible and acceptable. If people don’t use health services because they do not trust them or find them unsafe, then they are more likely to become very ill or die unnecessarily.
The health system is not accessed equally by all Australians who need it. For example, Aboriginal and Torres Strait Islander people access health services at less than half of their expected need. Safety and quality of care are also linked with culture and language. Research shows that people from minority cultural and language backgrounds are more at risk of experiencing preventable adverse events compared to white patients.
In Australia lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) people often receive inappropriate medical care, and experience health inequities compared to the general population around drug and alcohol use; sexual health and mental health issues.
Discrimination, transphobia, homophobia and a lack of cultural safety from health professionals discourage help seeking. Having services that are welcoming and safe would facilitate equitable health outcomes for all these groups.
There is no objective assessment of what constitutes “cultural safety”.
Correction: Only the person and/or their family can determine whether or not care is culturally safe and respectful.
The most transformative aspect of cultural safety is a patient centered care approach, which emphasises sharing decision-making, information, power and responsibility. It asks us as clinicians to demonstrate respect for the values and beliefs of the patient and their family; advocating for flexibility in health care delivery and moving beyond paternalistic models of care.
Patient-centred care is institutionalised in the Australian Charter of Health Care Rights (ACSQHC, 2007) and the Australian Safety and Quality Framework for Health Service Standards (2017) Partnering with consumers (Standard 2).
Cultural safety challenges nurses and midwives to work in partnership with people and communities but acknowledges that the system is weighted towards the interests of those who work in the system. We think we give the same care to everyone, but everyone experiences our care differently.
Once we understand ourselves and our health system as having a culture that privileges some people over others – whether we are conscious of it or not – we can get on with the real work of implementing better healthcare experiences for Aboriginal and Torres Strait Islander peoples and other marginalised groups.
” Cultural safety requires embedding in not only course accreditation for each health profession — including measures to reduce resistance — but also in the standards governing clinical professionalism and quality, such as the Royal Australian College of General Practitioners Standards for general practices,19 and the Australian Commission on Safety and Quality in Health Care National safety and quality health service standards.20
Such commitment will need investment in clinician education and professional development, together with measures for accountability. The stewards of the National Aboriginal and Torres Strait Islander Health Plan5 (ie, the Department of Health and their expert implementation advisory group), accreditation bodies, and monitors of the existing frameworks of safety and quality standards in health care need to formally collaborate on a systematic revision of standards to embed culturally safe practice and develop health settings free of racism.”
In Australia, the existing health safety and quality standards are insufficient to ensure culturally safe care for Indigenous patients in order to achieve optimum care outcomes.
Where “business as usual” health care is perceived as demeaning or disempowering — that is, deemed racist or culturally unsafe — it may significantly reduce treatment adherence or result in complete disengagement,1,2 even when this may be life-threatening.3
Peak Indigenous health bodies argue that boosting the likelihood of culturally safe clinical care may substantially contribute to Indigenous health improvement.4 It follows that a more specific embedding of cultural safety within mandatory standards for safe, quality-assured clinical care may strengthen the currently inadequate Closing the Gap mechanisms related to health care delivery.
The causes of inequitable health care are many. Western biomedical praxis differs from Indigenous foundational, holistic attention to the physical, emotional, mental and spiritual wellbeing of the person and the community.5 An article published in this issue of the MJA6 deals with the link between culture and language in improving communication in Indigenous health settings, a critical component of delivering cultural safety.
Integrating cultural safety in an active manner reconfigures health care to allow greater equity of realised access, rather than the assumption of full access, including procession to appropriate intervention.
As an example of the need to improve equity, a South Australian study found that Indigenous people presenting to emergency departments with acute coronary syndrome were half as likely as non-Indigenous patients to undergo angiography.7 More broadly, Indigenous people admitted to hospital are less likely to have a procedure for a condition than non-Indigenous people.8
Cardiovascular disease is the leading cause of death in Indigenous Australians.9 Cancer is the second biggest killer: the mortality rate for some cancers is three times higher for Indigenous than for non-Indigenous Australians.10 Clinical leaders in these two disease areas have identified the need for culturally safe health care to improve Indigenous health outcomes.
Cultural safety is an Indigenous-led model of care, with limited, but increasing, uptake, particularly in Australia, New Zealand and Canada. It acknowledges the barriers to clinical effectiveness arising from the inherent power imbalance between provider and patient,11 and moves to redress this dynamic by making the clinician’s cultural underpinning a critical focus for reflection.
Moreover, it invites practitioners to consider: “what do I bring to this encounter, what is going on for me?” Culturally safe care results where there is no inadvertent disempowering of the recipient, indeed where recipients are involved in the decision making and become part of a team effort to maximise the effectiveness of the care. The model pursues more effective practice through being aware of difference, decolonising, considering power relationships, implementing reflective practice, and by allowing the patient to determine what safety means.11
Along with an emphasis on provider praxis, cultural safety focuses on how institutional care is both envisaged and delivered.12 Literature on cultural safety in Australia is scant but growing.13 Where evidence is available, it identifies communication difficulties and racism as barriers not only to access but also to the receipt of indicated interventions or procedures.11
There is evidence of means to overcome these barriers. An Australian study undertaken across ten general practices tested the use of a cultural safety workshop, a health worker toolkit, and partnerships with mentors from Indigenous organisations and general practitioners.13 Cultural respect (significant improvements on cultural quotient score, along with Indigenous patient and cultural mentor rating), service (significant increase in Indigenous patients seen) and clinical measures (some significant increases in the recording of chronic disease factors) improved across the participating practices.
In addition, a 2010 study by Durey14 assessed the role of education, for both undergraduate students and health practitioners, in the delivery of culturally responsive health service, improving practice and reducing racism and disparities in health care between Indigenous and non-Indigenous Australians. The study found that cultural safety programs may lead to short term improvements to health practice, but that evidence of sustained change is more elusive because few programs have been subject to long term evaluation..
Newman and colleagues10 identified clinician reliance on stereotypical narratives of indigeneity in informing cancer care services. Redressing these taken-for-granted assumptions led to culturally engaged and more effective cancer care. In a similar manner, Ilton and colleagues15 addressed the importance of individual clinician cultural safety for optimising outcomes, noting that provider perceptions of Indigenous patient attributes may be biased toward conservative care.
The authors, however, went beyond the clinician–patient interaction to stress the outcome-enhancing power of change in the organisational and health setting. They proposed a management framework for acute coronary syndromes in Indigenous Australians.
This framework involved coordinated pathways of care, with roles for Indigenous cardiac coordinators and supported by clinical networks and Aboriginal liaison officers. It specified culturally appropriate warning information, appropriate treatment, individualised care plans, culturally appropriate tools within hospital education, inclusion of families and adequate follow-up.
Willis and colleagues16 also called for organisational change as an essential companion to individual practitioner development. Drawing on 12 studies involving continuous quality improvement (CQI) or CQI-like methods and short term interventions, they acknowledged evidence gaps, prescribing caution, and argued for such change to be undertaken in the service of long term controlled trials, as these would require 2–3 years to see any CQI-related changes.
Sjoberg and McDermott,17 however, noted the existence of barriers to change: the challenge (personal and professional) posed by Indigenous health and cultural safety training may not only lead to individual but also to institutional resistance.17 Dismantling individual resistance requires the development of a critical disposition — deemed central to professionalism and quality18 — but in a context of strengthened and legitimating accreditation specific to each discipline. The barriers thrown up by institutional resistance, manifesting as gatekeeping, marginalisation or underfunding, may require organisational change mandated by standards.
Colleen lives in Brisbane and through her blog she has become a support person for other Aboriginal people facing cancer, helping them with practical matters and being a friendly voice on the other end of a phone line.
She also accompanies some patients to hospital appointments and would like to see it made easier for Aboriginal volunteers to do such work.
“If you come from the Torres Strait and you’ve come down here and someone’s speaking to you really fast, rattling off all these medical things you’ll kind of be going, ‘what?’,” she said.
“If you’ve got someone, one of your own mob there it makes it easier.”
Close the Gap should be so much more than a photo opportunity or a morning tea. There are ways that everyone can help. I am going to share ten simple ones that I have been trying to get happening for years.
More Indigenous hospital liaison officers– Whatever title you use, we need more people in the hospital working for us. Big hospitals often only employ two, that is not even close to being enough. They should be employed around the clock.
Indigenous hospital volunteers– Hospitals need to have a separate army of volunteers, who deal exclusively with Indigenous patients, to spend time with the person from a remote area in a city hospital. To sit with someone having a long treatment. Just a friendly face in an alien environment.
Cultural Awareness Training (CAT) – Should be compulsory with all hospital staff, from the cleaner to the director. This training should address the issues and problems in health, but also needs to be localised to have the Traditional Owners from the area to share their knowledge. To truly let people understand, I am not talking a one of two-hour session a year, but a long, fully-formed training, with refresher courses each year. All medical and Allied Health professionals should do, and be assessed on, Cultural Awareness on a regular basis, and this needs to be registered. It is not good enough when a health professional does one course on Indigenous People and 20 years later still think that was enough. General Practice also need to have CAT, even if they are not signed on to CTG, because they are going to be seeing Indigenous patients.
General Practice incentive payments– GPs must lose their incentive payments if they sign on for the incentive and, during that time they don’t see an Indigenous patient. Again, they should lose the bonus if they are signed up and do not annotate the prescriptions for patients.
Indigenous people have the right of choice– We should be able to see a private GP or the local Indigenous Medical Service, or both if we want, but some funding seems to steer us towards the Indigenous Medical Service. This can be hard if it’s a long way from your home and you have to depend on public transport.
Employ more Indigenous peoplein the health sector, not just doctors – It can be as simple as a receptionist, who makes a difference.
Indigenous patients must be heard– Not just in the surgery but on national committees. Our experiences must be more than just fodder for researchers or funding applications.
Buck-passing – PHNs, Division of General Practices and other organisations, must stop handing over Indigenous units to others. You have patients that see so many doctors, you have to be responsible. Handing units over to Indigenous Medical Services etc, is passing the buck. It takes away our free choice. It is a way of saying you are not interested in our wellbeing.
Respect– Invite Elders to your hospital, clinic, whatever, on a regular basis, consider having an Elder in residence at your local hospital.
Recognise and celebrate our important dates– It smacks of racism if a hospital is decked out in green and shamrocks everywhere for St Patrick’s day and come NAIDOC, there is a morning tea, hidden away, with only a few people involved. Share it. Don’t even get me started on Australia Day. (Okay, just a little bit) Understand that we don’t think it’s great to wave the flag or want to be in your premises when you have complete overkill of decorations and start talking about how wonderful it is.
The unspoken illness: Cancer in Aboriginal communities
” Death by racism should be a category on death certificates, because the racism in hospitals is hindering the recovery of many Aboriginal and Torres Strait Islander people.
Spend some time as a patient in a hospital and you soon find out that the medical profession is full of bigots and people who might not consider themselves racist, but have preconceived ideas on race and hold outdated beliefs in racial stereotypes.”
We need cultural awareness programs on all levels of the system, writes Colleen Lavelle for IndigenousX : Our stories, our way” – each week, a new guest hosts the @IndigenousX Twitter account to discuss topics of interest to them as Aboriginal and/or Torres Strait Islander people. Produced with assistance of Guardian Australia staff.
I have been in and out of hospital for years with a brain tumour and have experienced the bigotry within the system first hand. I have also collected stories from Indigenous people around the country and a common thread is either: “Is it me or do they treat all of us like this?” or “Am I being overly sensitive?”
Indigenous cancer patients have even had pain relief denied to them. This might happen for a couple of reasons. First, because apparently some people think we Indigenous people can cope with more pain than our European counterparts. Let me state now that that ethnocentric view is not true. Another common view is that we are “faking it” to get drugs. Now, I don’t know about you, but if someone has cancer and is crying in pain, it’s pretty obvious they are not trying to get some cheap thrills.
A similar misconception is that we are drunk. I have even heard of cancer patients having their blood alcohol level tested before a doctor will see them. This assumption that we all take drugs or drink is outdated and just insulting.
Traditional people from remote communities have had to deal with their cultural mores being completely overlooked. Men have been shamed by having a young female nurse attend to them, when a male nurse is required. The same happens to our women too: a male attendant will try to do something that should only be done with or by a female. And when women ask to have another female in with them, they are quite often overlooked. I can’t understand why our cultural needs are overlooked when other peoples have their cultural rules respected.
The medical system seems so against us in so many ways, particularly if we are sent to a hospital away from home and English is not our first language. Good luck trying to find a translator to help! Governments, both at state and federal level can’t say they are doing all they can when our needs are not even considered important. All we hear are excuses like, “The cost is prohibitive for translators, patient transport, mobile medical units …”
We are the first people of this country and as such we shouldn’t be constantly overlooked. Perhaps fewer trips to the Gold Coast and a little bit more money into Indigenous health could help.
There are ways to make the road to good health better. For starters, no doctor or nurse should be allowed to work with Aboriginal people unless they have had cultural awareness training. It should be a requirement that all medical professionals do a cultural awareness course, with a refresher course after every year. Make it part of the accreditation process. It should be a part of the Close The Gap scheme that every general practice has to sign on to do cultural awareness. Even if it’s just one person in the practice doing it online. There could also be an incentive, such as the practice receives money for each Indigenous patient they see.
If every doctor and nurse across the country had this training and if hospitals and health executives spent quality time with Aboriginal and Torres Strait Islander patients, they might learn we are not so different. We might have some different needs, but they shouldn’t compromise the levels of compassion, caring and proper medial attention that we need.