Historically, the Australian health system has not provided safe and high-quality care to meet the needs of Aboriginal and Torres Strait Islander people.31 The health system in the past included segregated wards and service entrances, deliberately different (substandard) care, forced removal of newborn babies from mothers who were considered ‘not competent’ or not able to provide the ‘right upbringing’, and removal of children from home while parents were sick in hospital and failure to return these children to their parents’ care. A study of 755 Aboriginal Victorians in 2013 reported that nearly all respondents (97%) had experienced at least one incident that they perceived as racist in the preceding 12 months.32 Institutionalised racism is ‘the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people’.33,34 This should be seen in the context of systematic racism, which ‘operates across political, legal, economic and social systems’34 and is a predeterminant of institutionalised racism. Both forms of racism result in assumptions and attitudes that lead to bias in the safety and quality of health care, and can result in inadequate care and poorer health outcomes for Aboriginal and Torres Strait Islander people. These historical events and experiences, coupled with personal and family experiences of institutionalised racism and disrespectful communication, contribute to mistrust in the system by Aboriginal and Torres Strait Islander people and, at times, an unwillingness to engage with healthcare services at all. A 2017 evaluation of Victorian hospitals found that Aboriginal and Torres Strait Islander people continue to experience hospitals as sites of trauma and the Aboriginal and Torres Strait Islander workforce experience dangerous levels of vicarious trauma, cultural load and isolation.35,36 The literature considers cultural awareness and cultural competency on a continuum, contributing to a culturally safe environment that is respectful of Aboriginal and Torres Strait Islander patients and workforce. Cultural awareness is a basic understanding that there is diversity in cultures across the population. Cultural competency extends beyond individual skills or knowledge to influence the way that a system or services operate across cultures. It is a process that requires ongoing learning.37-39 One-off training does not create a culturally competent workforce, but could increase cultural awareness.40 A culturally safe workforce considers power relations, cultural differences and the rights of the patient, and encourages workers to reflect on their own attitudes and beliefs.1 Cultural respect is achieved when individuals feel safe and cultural differences are respected.1,41 Benefits for the health service organisation include:What is cultural awareness and cultural competency?
What are the benefits of taking action?
- A whole-of-organisation and whole-of-system approach to improvements for Aboriginal and Torres Strait Islander people
- Effective and appropriate communication with Aboriginal and Torres Strait Islander patients and families that minimises discrimination
- Reduction in clinical variation across the patient population
- Cost-effective and efficient delivery of care
- Greater cultural capability, which could benefit all vulnerable or culturally and linguistically diverse patients
- Increased understanding of Aboriginal and Torres Strait Islander health issues, health needs, and the complex personal experience of individuals, families and communities
- Increased understanding of the diversity of Aboriginal and Torres Strait Islander communities
- Reduced stress for the organisation’s Aboriginal and Torres Strait Islander workforce from a reduction in racially discriminatory practices, and subsequent reduction in their vicarious trauma, cultural load and isolation
- Increased recruitment and retention of the Aboriginal and Torres Strait Islander workforce
- Increased confidence of the overall workforce in interacting with Aboriginal and Torres Strait Islander patients and their families42
- Increased confidence and satisfaction of all employees who provide care for Aboriginal and Torres Strait Islander patients
- Reduction of racism and discrimination
Benefits for the Aboriginal and Torres Strait Islander community include:
- Improved patient perceptions and experiences of care within the health service organisation
- Greater ability of patients and families to be involved in health care43,44
- Improved wellbeing of the Aboriginal and Torres Strait Islander workforce through the reduction of racially discriminatory practices
- Increased access to the health service organisation by Aboriginal and Torres Strait Islander people
- Improved equality and reduced disparity of health outcomes.
Key tasks
- Use the national Cultural Respect Framework 2016–2026 for Aboriginal and Torres Strait Islander Health to develop, implement and evaluate cultural awareness and cultural competency strategies1
- Implement an ongoing professional development program of cultural awareness and cultural competency that is tailored to the needs of the local Aboriginal and Torres Strait Islander community
- Evaluate the effectiveness of the cultural awareness and cultural competency strategies
- Develop and maintain mechanisms to partner with Aboriginal and Torres Strait Islander communities to gain feedback on, and improve, cultural competency
- Develop and implement an Aboriginal and Torres Strait Islander employment strategy that incorporates:
- training and ongoing professional development processes
- workforce support, including systems to retain employees and provide appropriate employee assistance programs
- recruitment of Aboriginal and Torres Strait Islander people to positions at all levels of the organisation
- increasing employment opportunities for Aboriginal and Torres Strait Islander leaders by establishing leadership development programs and pathways
- Use continuous quality improvement processes to improve the cultural safety of the health service organisation
- Incorporate into the professional development program opportunities to discuss and develop the workforce’s cultural awareness and cultural competency
- Report on the effectiveness of the cultural awareness and cultural competency training to the governing body, the workforce, and the Aboriginal and Torres Strait Islander community.
Suggested strategies
Cultural safety is about creating an environment that is safe for Aboriginal and Torres Strait Islander people. This means there is no assault, challenge or denial of their identity and experience.
Cultural safety is about:
- Shared respect, shared meaning and shared knowledge
- The experience of learning together with dignity and truly listening
- Strategic and institutional reform to remove barriers to the optimal health, wellbeing and safety of Aboriginal people. This includes addressing unconscious bias, racism and discrimination, and supporting Aboriginal self-determination
- Individuals, organisations and systems ensuring their cultural values do not negatively impact on Aboriginal peoples, including addressing the potential for unconscious bias, racism and discrimination
- Individuals, organisations and systems ensuring self-determination for Aboriginal people. This includes sharing power (decision-making and governance) and resources with Aboriginal communities. It's especially relevant for the design, delivery and evaluation of services for Aboriginal people.
Key elements of culturally safe workplaces and services
Knowledge and respect for self: Awareness of how one's own cultural values, knowledge, skills and attitudes are formed and affect others, including a responsibility to address their unconscious bias, racism and discrimination.
Knowledge and respect for Aboriginal people: Knowledge of the diversity of Aboriginal peoples, communities and cultures, and the skills and attitudes to work effectively with them.
A commitment to redesigning organisations and systems to reduce racism and discrimination: Strategic and institutional reform to remove barriers to optimal health, wellbeing and safety outcomes for Aboriginal people.
Cultural safety is an ongoing learning journey: An ongoing and response learning framework that includes the need to unlearn unconscious bias and racism and relearn Aboriginal cultural values.
Why is cultural safety important?
Cultural safety is a fundamental human right. It's also a legislative requirement of public agencies to provide safety in the workplace.
The workplace environment, services and settings for health, wellbeing and safety must be culturally safe for all people.
For a fair and equitable society free from racism and discrimination, we must address the underlying causes of culturally unsafe practice.
Everyone's responsibility?
Everyone has a responsibility for the cultural safety of Aboriginal people in their organisation. Everyone is responsible for how they work with Aboriginal staff, health consumers and clients of community services.
Aboriginal and Torres Strait Islander cultural safety framework
The Aboriginal and Torres Strait Islander cultural safety framework has been developed to help mainstream Victorian health, human and community services and the department to create culturally safe environments, services and workplaces.
The framework provides a continuous quality improvement model to strengthen the cultural safety of individuals and organisations.
It aims to help the department and mainstream health, human and community services to strengthen their cultural safety by participating in an ongoing learning journey.
We would like to acknowledge the following people and groups for their contribution to the early conceptualisation of the framework:
- Professor Gregory Phillips, CEO, ABSTARR Consulting
- DHHS Aboriginal employment subcommittee
- DHHS Aboriginal Staff Network
- DHHS Pilot Groups.
For a copy of the Aboriginal and Torres Strait Islander cultural safety framework, please email .