A Symposium on "Cultural Safety" & the State of Health: Alice Springs (2013) Prof. Bob Morgan.( Draft Summary Notes)

WHY a symposium on CULTURAL SAFETY: What emerged - a culturally safe framework requires open hearts & systemic reform within health care services... & why is this a still a relevant concern?

 “The real political task in a society such as ours is to criticise the workings of institutions that appear to be both neutral and independent, to criticise and attack them in such a manner that the political and cultural violence that has always exercised itself obscurely through them will be unmasked, so that one can fight against them.”(Michel Foucault, The Chomsky - Foucault Debate: On Human Nature)

1. Symposium Focus

The symposium focused on showcasing and determining the requirements for providing culturally safe health work environments and management practices within Aboriginal and Torres Strait Islander health services. 

Despite a growing body of critical scholarship on cultural awareness, the concept of ‘culture’ continues to be applied in ways that diminish the significance of power relations and structural constraints on health and health care. This symposium attempted to take a critical look at how assumptions and ideas underpinning conceptualisations of culture and cultural sensitivity can influence the delivery of service and the workplace experience of Aboriginal people within the health care systems.

It explored the necessity of health care workers and service providers to develop greater critical awareness of culture as a relational process, and as one necessarily influenced by issues of racism, colonialism, historical circumstances, and the current political climate in which they live. It is anticipated that the cultural safety practice framework will act as a supplement to the Australian Government Health Ministers stated commitment to enacting the National Strategic Framework for Aboriginal and Torres Strait Islander Health Workforce (2011 – 2015).

The symposium hoped to draft a national framework for culturally safe  work  practices in the Health Industry under the auspice of the Occupational Health and Safety legislation. This Framework aims to recognise the need to strengthen the ability of health services to deliver culturally safe healthcare and to also build community expertise to respond to health needs. This includes effectively equipping staff with appropriate cultural knowledge and expertise in delivering clinical care in a culturally responsive and safe manner. 

 The symposium coordinating committee assembled an impressive group of health professionals and academics including Dr Rose Roberts from Canada and Ms Dianne Wepa from New Zealand. In addition to the international presenters notable Australians including Dr Jeff McMullen AM, Professor Rob Tierney from Sydney University and Mr. Pat Maher, from Health Workforce Australia (HWA) have also been invited as keynote presenters.

The symposium represented a commencing point not a final destination, as attentiveness to issues of health care and culture continue to be a major priority in Australia. As well as sharing important information on existing practices, what emerged from the symposium was the origins of a clear workable framework to guide the design and delivery of culturally safe health care and culturally safe work environments.

 During the symposium members of the National and Aboriginal and Torres Strait Islander Health & Workers Association (NATSIHWA) affirmed a strong commitment to partnering with relevant health service providers and systems to ensure that a more culturally responsive and accommodating healthcare service is provided to address the ongoing health and wellness needs of the and Torres Strait Islander communities from across Australia. It calls for a revisionist approach to pre-service and in-service training that moves beyond the tick box methodology of many cultural awareness programs towards an efficacy of (the science) the heart that recognises the earth is alive and we have reciprocal responsibilities to it and our fellow humans.

PREMISE: “Cultural Safety extends beyond cultural awareness and cultural sensitivity. It empowers individuals and enables them to contribute to the achievement of positive outcomes. It encompasses a reflection on individual cultural identity and recognition of the impact of personal culture on professional practice.”

2.Literature Review

 Browne and Smye (2002) argue that within western health care systems, there is a tendency to still medicalise social problems as arising from lifestyles, cultural differences or biological predispositions’. Colonial attitudes still influence policy and although the word post- colonialism now enjoys a growing popularity with policy makers, Battiste (2004:1) has suggested that the word ‘postcolonial’ is a conception that is somewhat misunderstood. She sees the term as a representation of ‘an aspiration, a hope, not yet achieved’ rather than relating to an era after colonialism. 

The 2005 Social Justice Report highlighted the poor state and lack of equality in Aboriginal health care in Australia and in response, the Council of Australian Governments (COAG) introduced a number of policy and programming initiatives in an attempt to significantly close the gap between Indigenous and mainstream Australians in many areas including health outcomes.

The Social Justice Report 2005 in commenting on equality of access issues in Australian health care advocated that to significantly close the gap between Aboriginal health and that of mainstream Australia, equality in health care and services is essential. While the gap is narrowing in some areas, Altman, Biddle and Hunter (2008) argue that on present progress, the actual time needed to close the gap may be significantly longer than the current governments predict.

Poor policy implementation, with little room for negotiation with communities and the failure to recognise the diversity of Aboriginal and Torres Strait Islander people through a “one size fits all” policy and programming approach has simply led to the continuation of stereotypes of dysfunction and recalcitrance by governments, the media and the public (Rowse 2006, Ingamells 2010). To effect serious change, attitudes need to change at an institutional level. In this context, cultural safety seeks to address issues that are situated within the social and political spheres of service delivery (Smye and Browne 2002).  

Rationale for Cultural Safety

 Historically, the lifestyle, beliefs and cultural identity of Aboriginal people (in Australia and internationally) have been ignored or denigrated by non Aboriginal service providers (Ball 2008) and it is anticipated that the adoption of cultural safety standards and practice within Australian health systems will significantly ameliorate this situation. 

 The concept of cultural safety had its origins in New Zealand in the 1980’s primarily through the work of Maori nurse Irihapeti Ramsden (Hally 2008) and inspired in part by the principles of protection, participation and partnership found in the Treaty of Waitangi (Woods 2010). The concept introduces a different way of looking at the inequalities that lie embedded in the health care system. Importantly, it seeks to challenge health professionals and health systems to critically examine the way they view Indigenous health and how they engage with Indigenous peoples. 

Cultural safety, it is argued can increase the likelihood of positive outcomes in relation to patients’ health because it identifies the information that is important and endeavours to deliver it in a way that it will be understood (Larson et al 1996) In addition, cultural safety has the potential to not only self empower the client but also the health practitioner (Richardson and Williams 2007) Bin Sallik (2003), sees cultural safety as extending beyond cultural sensitivity and cultural awareness in that it empowers the clients to contribute to the achievement of positive outcomes. It is perhaps this emancipatory aspect of cultural safety that can contribute most to self-determination.  

Johnstone and Kanitsaki (2007) are of the view that in Australia, cultural safety should be extended to be standard practice for the care of people from more diverse racial and ethnocultural backgrounds .

While much has been written about cultural safety from the viewpoint of power relationships between health care professionals and patients, it is invariably the institutions (hospitals, government departments, schools etc.) which need to adhere to the cultural safety formula in order to ‘effect cultural change in the design and delivery of policy’ (Brascoupe and Waters 2009)

3. What the Symposium Recognised

1.A Culturally Safe Framework requires self-reflexive leadership and good governance to ensure Aboriginal and Torres Strait Islander health professionals, including Aboriginal and Torres Strait Islander Health Workers, are recognised and respected for their expertise in the delivery of culturally safe health care. Cultural Safety is a relational process that involves all levels of an organisation that has its origins in cultural awareness competencies and moves beyond to engage both service provider at the operational and service recipient domains. Such an approach recognises that cultural safety is the responsibility of all stakeholders, including the Indigenous community, to respond with respect for the other through an advocacy of self-determination, equity and restorative justice.

2.We need to move towards individual localised narratives of celebration and recognition of kinship ties that have remained resilient. Cultural awareness approaches towards Indigenous Australia tend to fall into the trap of cultural minimalism, reducing culture to a museum approach based on the simple teaching of ritual and custom that has a proclivity to stereotype and legitimise knowledge and power relations in the hands of a dominant white Australia. What needs to be recognised is that there is no basis to learning a culture that is not our own, whether traditional or modern. All we can do is reflect upon our own and honour the diversity of others.  [anthropologist, Inge Riebe]

What we need to do is create the space for cultures to co-exist and thrive for the mutual benefit of all. In other words the essence of a cultural safety framework will be rendered ineffective if it only draws on western traditions without a custodial referenced understanding of First Nations people and their connection to land whose sovereignty has never been ceded.

I might look middle class and assimilated to outsiders but my father and his generation did not want us growing up to be white. It was important to him that I knew my culture , my place in the world, that I understood the cultural values of reciprocity, interrelatedness to the environment, obligation to country , respect for Elders. He wanted me to know my totems and my dreaming. He knew that without this, I would not be complete. (Larissa Behrendt is a Eualeyai /Kamillaroi woman and Professor of Law UTS)

We need to create culturally safe workplace environments for ATSI Health Workers that recognise - Key Performance Area 3 of the National Strategic Framework for Aboriginal and Torres Strait Islander Health Workforce (2011 – 2015) highlights the need for a “…competent health workforce to meet the needs of Aboriginal and Torres Strait Islander people” and states the following outcome requirement “…the roles, skills and cultural knowledge of other health workforce groups are appropriate to health service delivery needs of Aboriginal and Torres Strait Islander peoples”.

3. Further what the symposium drew attention to, was the potential limitations in a framework that adopts a culturally sensitive (or cultural awareness) approach with its workforce “…without first examining what was meant by culture, and even more important what our own values are with respect to the culture of the Other” [Lock;1993] To do this, we must first take a look at how understandings of culture have been shaped over time within our profession, within health care more widely, and by wider societal discourse. [Browne &Varcoe: 2006]  There is a semantic ambiguity that seems to pervade the understanding of ‘cultural safety’. Quite clearly from the research seemingly synonymous concepts such as cultural learning, awareness, competency and capability are often used interchangeably with cultural safety creating an illusion in the workplace of cultural ethics without adequately addressing the potentially transformative qualities that cultural safety frameworks attempt to address.

Culturally Safe spaces find their frame of reference in our individual humanity and ability for deep self-reflection upon notions of culture and relational connections with others. Cultural awareness programs and their progeny tend to be skills- based frameworks that may form subsets on the path to cultural safety. On the other hand cultural safety frameworks are less about intellectual integration of another’s culture as a learned mechanism through which to navigate the world, and more about a movement of the heart and self-knowledge of one’s own cultural lens. Moreover cultural awareness approaches seem to suggest an endpoint of capability acquisition in the area of culture, whereas the concept of cultural safety recognises culture as a circular haecceity ; a never ending process of connection, accommodation and self- reflection.  This has profound implications for the reception of cultural groups in our society who are the most disenfranchised within the workforce. As Toni Morrison reminds us the function of freedom is to free someone else for the benefit of all.

Reflection-recognition-respect

Two key questions for reflection underpinned the symposium:

1. Has the case for ‘cultural safety’ been made?

2. If it has been made within you workplace contexts, what do you consider to be some of the impediments towards the development of a cultural safety framework for ATSI health workers?

 TOWARDS A DRAFT FRAMEWORK FOR CULTURAL SAFETY

(What are some the principles that underpin cultural safety?)

A culturally safe framework that could significantly advance the delivery of health services and Aboriginal and Torres Strait Islander well being would necessitate internal systemic reflection beyond the deficit theories that have traditionally framed Indigenous peoples.

Deficit theories, in relation to our Aboriginal people, promulgate the idea that indigenous gaps in health provision and education retention rates have more to do with a litany of social and psychological discrepancies in Aboriginal adults and their parenting; in their home life; and /or in their community. Such paternalistic perspectives see the fault or “gap” (as in closing the gap) as having its genesis in the people not in the systemic delivery; the system is fine, but the clients are lacking.

Culturally safe practices need to take providers away from this looking glass of deficit towards enabling practices that are in tune with consequences of colonisation upon Aboriginal people, that let the worker and client define what is safe for him or her and what binds them to a healing time that is mutually beneficial.

Cultural safety for Aboriginal and Torres Strait Islander workers and clients has its genesis in a systemic shift in government policy and health care organisations. Until we embrace with deep commitment the ramifications of colonisation upon indigenous people in this country, we may need to go backwards, absorbing a new understanding and respect for history, before we go forwards to stop the blame the victim mentality and other related discourses that seem to be endemic in government social policies and practices towards Aboriginal people.  As a nation we may first need to learn to walk in others shoes to realize with deep proactive compassion that on all OECD indicators of wellbeing we are the worst performing nation with regards to health and education advancement of our indigenous peoples even though we have the most buoyant economy in the western world along with Switzerland, and a national debt that is only 6% of our GDP.[see Prof. Rob Tierney’s attachment]

Day 1:Theme ~ Exploring Current Realities       [25/3/2013]

“… each is itself and no other thing. It’s plurality we experience; it is differences, not the smear of Oneness; the haecceity that we knew as children" (from the Drift of Things ;Robert Gray)

1.Acknowledgement of Country

Aunty Doris and Aunty Elaine [Arrente women from Central Australia]

The symposium opened with a poignant remembrance of the secret history and shame that lies beneath the surface of contemporary Australia and eludes the majority of the Australian population as they walk upon this ancient continent. Aunty Doris informed us that the symposium site, now the Crowne Plaza Hotel, was traditionally a restricted area where only Aboriginal people could enter, but now is known as “Broken Promise Drive” by the local Arrente community. Its official name is Barrett Drive but what this nondescript reference masks is the site damage that occurred when Lasseter's Hotel Casino was built in 1980.

Without consultation the bend in the road was straightened removing ancient sacred trees and sealing sites of sacred cultural significance that impinge on the wellbeing of the local Arrernte people to this day. The Northern Territory Government in secretly employing contractors to straighten Barrett Drive broke their initial promise to the local indigenous community to consult and in the process repeated the cultural damage that had preceded during the widening of the Gap Rd entrance and development of Alice Springs in the name of commercial development. These were important caterpillar creation trees that went to the very heart of the local indigenous people’s genesis stories and as Aunty Doris and Elaine reinforced site damage destroys people as well as places.  They stressed there is no medicine to fix what Aboriginal people are feeling because history, as it is presently constructed, denies a tree is our grandmother and when you build you are destroying a portion of us.  

See our country through our people’s eyes, Our spirits and our people have had to die

All because people…People will never feel it because it is not their land, that word we all know COMPROMISE.      Fragments from a poem COMPROMISE by Aunty Doris’s son

There was no formal welcome, only an acknowledgement of fore- bearers. The elders expressed a strong feeling that to welcome others is to continue on the path of the potential destruction of their culture and our people.

Aunty Doris’s acknowledgement to Country, from the outset of the symposium reminded every delegate that without reflection, recognition, respect for history and the life chances that have been denied indigenous people through an appropriation of their unceded sovereignty, there can be no culturally safety for Aboriginal and Torres Strait Islander peoples, whether in the workplace or any other context.  Broken Promise Drive is a tragic reminder of this, and how the rights of the local people have been whitewashed as recently as 1980. No mention of what happened here is formerly recorded any where; all that remains are the memories and oral recordings of local history by Arrernte people and elders such as Aunty Doris and Aunty Elaine and the need for white Australia to awaken, listen deeply and acknowledge the spot we stand upon.

Day 1: Speaker 1 -Warren Snowdon, Minister for Indigenous Health.(NT)

The Honourable Minister, Warren Snowdon opened the symposium by advocating that Health Workers were at the centre of closing the gap and delivering health services. In particular Aboriginal Health workers can provide the context for non -Aboriginal health workers. There was a general agreement of the importance of understanding context anywhere in the world but when it comes to Aboriginal health workers we don’t do this. We all have different histories and there is vast diversity and difference in this country yet we when we talk of Aboriginal and Torres Strait Islanders we believe we can do ONE cross cultural training course, but this is not so. We must talk to the locals and learn about their traditional practices, priorities, culture etc, in each new context. Aboriginal and Torres strait Islander Health Workers “should be at the forefront of every clinic in the country. They need to be valued for themselves and the cultures they represent.”

Cultural Safety must understand the country and the cultural protocols of that country. There needs to be a holistic approach where the whole context needs to be understood. The best health services are those where the vibrancy of the local community is at the centre of the service. Health Organisational structures need to have a place for CULTURAL GOVERNANCE that sits alongside Clinical Governance, Administration etc.

Speaker2: Dr Rose Roberts

Cultural Safety: The Canadian Indigenous Experience.

Dr Roberts provided the symposium with a description of how Cultural Safety is becoming an integral part of health care pre -service education as well as in the health care work environment in Canada. Her paper also clearly asserts that the practice of Cultural Safety by health care workers towards their clients has been a necessary response by Indigenous Canadians to a colonial history which has seen them dispossessed, disempowered, and oppressed by colonial forces which sought to assimilate the Indigenous peoples and in doing so strip them of their cultural identity. She references George Erasmus, the director of the Aboriginal Healing Foundation, who said that it would take at least 30years to heal from the effects of colonialism and its oppressive impact upon the Indigenous people. Colonised people are reduced to “something one judges (as in a court of law), something one studies and depicts (as in curriculum), something one disciplines (as in a school or prison), something one illustrates (as in a zoological manual)” and also experience similar health disadvantages. Indigenous Canadians share many of the same health statistics as those in Australia, Aortorea and the United States with their respective Indigenous populations. These include ,Canadian Aboriginal People QOL 56th in the world,TB – 8-10 times higher, chronic diseases - diabetes & heart disease, infant mortality rates twice as high as Canada as a whole and Life expectancy is lower: Higher risk for illness and early death. Dr Roberts outlines this history of colonialism which included oppressive and assimilation policies and decisions imposed upon the Indigenous people. They were forced to endure treaties, the Indian Act, Residential schools and Reserves, each of which determined to ensure cultural degradation. These impacted upon the future cultural environments created by healthcare organizations within which Indigenous people worked and attended as patients. Instilled within these structures were barriers to culturally competent care which were characterized by a lack of diversity in organizational leadership and work force, systems poorly designed to meet needs of diverse populations and poor communication between health professionals and patients from different backgrounds. These unsafe practices were strengthened by the underlying oppression that existed through the exercise of authority or power in a burdensome, cruel or unjust manner, social oppression, systematic oppression and internalized oppression. Each of these reinforced the effects of colonisation and othering on the colonised, hopelessness, powerlessness, anomie, abuses, pain of generations, conflict within communities, Ethno-stress and Internalized Oppression – Lateral Violence.

In defining the practice of Cultural Safety, Dr Roberts utilises the metaphor of the iceberg as a means of illustrating the deeper exploration of cultures that a Cultural Safety paradigm expects of individuals in the workplace and which is necessary for more meaningful connections with others. She goes on to explain that this metaphor suggests that we can only see 10% of an iceberg, the other 90% is underwater and as the Titanic found out, it’s the unseen part that can be the most dangerous. It can be the same with culture. Such "visible" elements include things as music, dress, dance, architecture, language, food, gestures, greetings, behaviours, devotional practices, art and more. The bottom side of the iceberg will include things such as religious beliefs, worldviews, rules of relationships, approach to the family, motivations, tolerance for change, attitudes to rules, communication styles, modes of thinking, comfort with risk, the difference between public and private, gender differences and more. She also refers to Peggy McIntosh’s metaphor of unpacking the white backpack in order for white people to understand the privilege they have just by the colour of their skin and to challenge this notion of privilege and what underlying assumptions it may hold, “Whites are taught to think of their lives as morally neutral, normative and average, and also ideal, so that when we work to benefit others, this is seen as work that will allow ‘them’ to be more like ‘us’”.

Dr Roberts continues by referencing her own model , below, which visually represents the process of Maintaining Cultural Integrity. She acknowledges that there are more than a few models that attempt to explain the interactions between cultural sensitivity, cultural competence and cultural safety. Her model is circular because she believes these interactions form a never-ending process, that culture is not static, and with the world becoming smaller, we are constantly being exposed to other cultures.

Cycle of raised consciousness moves in clockwise direction from 'Cultural Sensitivity ~ Cultural Competence ~ Cultural Awareness.( Maintaining Cultural Integrity? Roberts, 2008)

The practice of Cultural Safety in the workplace and embedded into the curriculum of nursing students, as it has been in Canada, demands that health care workers reflect deeply about such things as the shaping of their beliefs and values and how they view health and illness, birth and death and how sick people should behave. Dr Roberts clearly states that Cultural Safety requires individuals to consciously consider their own enculturation process and assumptions that there is no such thing as an unbiased health care worker. Everything we see, everything we do is seen through the lens of the specific health belief model we have. In Canada cultural safety  is approached from the perspective of cultural competency where culture is learned and transmitted from generation to generation – mainly through childhood and during maturation. This means humans are highly adaptable to different cultural environments. Enculturation is the process of learning one’s culture through informal and formal instruction. Significantly, Dr Roberts concludes that we can acquire any culture if we are inducted through deep human connection. This level of awareness and understanding, however, is also a process and involves experiencing stages of transitions before transformation of individuals and organizations can be borne. Each stage is characterised by a specific feature which translates into behaviour. Stage 1 is Discomfort, stage 2 is Going Internal, stage 3 is Exploration and Stage 4 is The New Beginning. These are stages that move from fear to contemplation and self reflection, to a willingness to experiment with new ideas and finally to a determination to make changes.

1.  Importantly she acknowledges that a culturally safe healthcare system doesn’t ‘just’ happen but rather, there has to be a process built into the system somewhere, preferably in “several somewheres”. In Canada one of those somewheres is with the Aboriginal Nursing Association of Canada or ANAC. ANAC has taken it upon themselves to come up with a set of core competencies for all nurses in Canada, the competencies to be taught within the nursing schools which include 6identified areas :Post-Colonial Understanding- the examination of colonisation and its effect on the lives of the Indigenous peoples of Canada.
2. Communication – the effective and culturally safe communication between nursing students and faculty, as well as interactions between nurses and Indigenous clients.
3. Inclusivity – where increased awareness and insights are required as part of the engagement and relationship process with Indigenous clients.
4. Respect – the show of consideration for indigenous students, clients, families, communities for who they are and for their uniqueness and diversity.
5. Indigenous Knowledge – the concept of acknowledgement of traditional knowledge, oral knowledge as having a place in higher learning. It also includes understanding Indigenous ontology, epistemology and explanatory models.
6. Mentoring & Supporting Students for Success – seeks to create a space where Indigenous nursing students will succeed in nursing education – because we have seen that universities are often unwelcome places for indigenous peoples.

Raised awareness about cultural safety and the embedding of culturally safe practices in the health care sector has significantly enabled Indigenous Canadians to find their own ways back to health and wellbeing. An example of this is the establishment of an organisation called Four Worlds Development Project that worked on creating a health determinants framework that is more suited for the worldview of Indigenous people. These include: basic physical needs, spirituality and sense of purpose, life sustaining values, morals & ethics, safety & security, adequate income and sustainable economies, adequate power and social justice and equity. Furthermore, the process of having a culturally safe place involves a spectrum that goes from individuals to the systems and organisational levels whereby Aboriginal people are part of the decision making process, and have access to the tools they need to care for their health and wellness and health care systems are aware of the resources and needs of Aboriginal people so these can be incorporated into practice. Overall, the following structural developments that have occurred in Canada are an indication that one is going in the right direction: Governance Examples which include a BC First Nations Health Authority, Northern Inter-Tribal Health Authority and Saskatchewan MOU on First Nations Health and Well-Being; Organisational Examples including Fort Qu’Appelle All Nations Healing Hospital, Saskatoon Health Authority/ Saskatoon Tribal Council and Saskatoon Westside Clinic; and finally Program Examples such as Aboriginal Healing Foundation,Aboriginal Health Human Resource Initiative and Kwan Lin Dun Healing Centre.

Dr Roberts concluded with a challenge and encouragement for the future of Cultural safety in Australia, “…open your mind to the potential of what is possible. Each of us walk in the path of our ancestors but sometimes we also need to create our own paths and when we have the courage to create a new way of being and doing, there will be challenges and obstacles, that annoying snip of a branch that swings in your face but you push it aside and keep going. And the more that you follow behind pushing aside that branch, the clearer the path will become”.

Speaker 2:  Toward a Redefinition of Equity  [Professor Rob Tierney, Dean of Faculty of Education & Social Work, Sydney University] 

Equity ~ Health & Education

Equity is widely seen as one of the basic necessities of life and the right to respect, societal participation, education, health care, food, information are recognised, for example, in the United Nations Declaration of the Rights of the Child and the constitution or related.

Education is a key determinant of both wages and employment opportunities (Booth et al., 2002; Dearden et al., 2000; Ok and Tergeist, 2003) and non-economic outcomes such as good health, longevity, and successful parenting (Dearden et al., 2000; Vernez et al., 1999; Osberg, 1998).

The National picture of Indigenous People

• For births between 2005 and 2007, estimated life expectancy for Indigenous males was 67 years, and 73 years for Indigenous females, compared with 79 and 83 years for non-Indigenous males and females.
• For 2006-07, Indigenous people had a hospitalisation rate 2.5 times the rate of non-Indigenous people.
• Young child mortality rates in the Indigenous population remain two to three times as high as those for all young children in Australia.
• In 2006, the proportion of Indigenous 19-year-olds who had completed year 12 or equivalent was 36%, compared with 74% for the non-Indigenous group.
• The unemployment rate for Indigenous people aged 15-64 in 2006 was 16%, compared to only 5% for non-Indigenous people.
• Median weekly incomes for Indigenous people aged 15 years and over ($278) were 58.8% of those of non-Indigenous people aged 15 and over ($473) in 2006.
• In 2008, Indigenous people were 13.3 times more likely than non-Indigenous people to be imprisoned.                                                                 [Table 1]

“There $12 million for Indigenous research allocated to Sydney University , but virtually no indigenous academics our doctoral students. The funding often absorbed by the opportunistic advancement of non-indigenous academics.”     ~ Prof.Rob Tierney

OECD Rankings (2012)

Domain . Indicator . OECD Ranking

1.Material Wellbeing: Reciprocal Deprivation . Australia (nationally) . 10/30

First Nations' Australians (only). 29/30 (only Turkey and Mexico have worse levels)

2. Infant Health. Infant Mortality. Australia. 20/27 (bottom third)

First Nations 26/28 (More than double the non-Indigenous rate)                                                                                                                        

Low birth weight . Australia . 7/18

First Nations . 19/19 (Lowest in the OECD and more than double the non-Indigenous rate)

Mental Health . Australia . 18/23

First Nations. 23/24

3. School Achievement at age 15 Reading Australia . 6/29

First Nations . 29/30

Maths . Australia . 8/30

First Nations . 29/31 ( Better only than Turkey and Mexico)

4. Family Relationships Sense of Belonging Australia . 11/29

First Nations . 29/30

5. Behaviour & Risks . Teenage Pregnancy Australia . 21/30

First Nations . 31/31 ( Five times the national average and worse than Mexico)

(TABLE 2)

Professor Rob Tierney in his presentation showcased the nexus between Education and Health, and the profound disparity in equity that informed their delivery to Indigenous Australians compared to other OECD countries. He argued that as a nation Australia struggles to understand what it means to be human through its secular materialism and cultures of individual greed. Much of our national rhetoric and dialogue around privilege and poverty is framed by economic outcomes and levels of capable integration. The belief that is sometimes perpetuated is that somehow disadvantaged groups are lesser people incapable of assimilating with the dominant culture of material individual development. Moreover he indicated that there appears to be a genuine perverse belief in this country, in the existence of a link between socio-economic status and intelligence and that advantage is genetically coded. This almost eugenic frame of reference is then also cast across cultural gaps or differences that deviate from dominant white secular materialism. Furthermore he emphasised that our capital as human beings is so economically commodified in the western world that it not only alienates us from ourselves, (possibly witness by the exponential uptake of antidepressant drugs in the past three decades), but also prioritises our worth in terms of economic contributors.

Thus, unsurprisingly he went on to stress that our record of service delivery and workforce practices with our Indigenous peoples are among the worst in the OECD countries juxtaposed with one of the highest standards of living in the world among our non-indigenous wider community. [see Tables 1& 2 supplied by Rob Tierney] Within this context Professor Tierney suggested that it is the language of ‘cultural safety’ that has the potential to carry metaphors and nuances which may empower Aboriginal and Torres Strait Islander people to be who they need to be for each other in the work place and to culturally and ethically frame how people in a broader multi-ethnic community think about themselves and act towards others. There was also a perceived need in the development of cultural safety frameworks to engage in a dialogue with new levels of militancy about the role of class and racism as contributing factors in the increasing inequities that inform Australian society.

What was emphasised through the lens of raised social awareness, was that cultural safety frameworks have the potential to draw us towards a deeper consideration of the values that underpin our species and the self-reflexive ethnocentric constructions of culture that drive perceptions of ourselves and others. It was noted that the “Closing the Gap” rhetoric of the Federal Government still positions indigenous people within the framework of deficit theories that make them responsible for their own lack of achievement in western terms. He traced this re-emergence of a kind of mission mentality towards indigenous people to the 1990s when there was a shift in the political rhetoric from equity and diversity to achievement gap and equal opportunity with its affiliated underlying assumptions of an equal playing field for all participants and its proclivity to simplify culture into sytematised facts that can be elicited as formula for policy.

If people start from unequal positions and you treat them equally all you do is entrench the inequality     - Sir Ronald Wilson Human Rights Commissioner/author with Mick Dodson ‘Bringing Them Home Report’

Rob Tierney argued that we need to take a broader 360* view of society beyond narrow standardised approaches that favour the rights of power and privilege. Primarily we need to connect with the specific culture of the people we are working with, beyond traditional top down approaches where we become allies in the empowerment and self-determination of minority groups through an examination of our own ethnocentric cultural mores and assumptions. Such an approach inverts traditional models of cultural interaction to a ground up approach that would involve a more concerted “action research” methodology in government and in the work place that observes good practice not a one size fits all tick box approach to policy and behaviour. Professor Tierney advocated research that is localised from the “ground up” which attempts to make space for indigenous pedagogy and cultural innovation in which workers are not being observed and economically commodified but engaged as participants in culturally safe ways.

He advocated for systemic introspection, where personnel are enabled to make a difference to social justice and effective health care delivery through relational community engagement and not solely through the lens of fixed cultural awareness indicators. Moreover he re-iterated that the basis for the future development of such culturally safe frameworks was the engagement by ATSI workers and professional affiliations of allies  from the wider Australian non-indigenous community who can walk in others shoes and be guided to move forward in the enabling of culturally safe work spaces. For Professor Rob Tierney this process is a fundamental journey towards human rights as we have all got a little lost in the prism of neo-liberal politics and the commodification of growth over humane development as a people.

Day2: Theme ~ Pathways of Hope [26/3/2013]

Going forward we may need to go backwards and journey along the ‘secret river ‘of history- the cultural continuity and pedagogy of our people 

Bad practice justifies itself with theory; good practice with its immediate sensory appeal.

Review:  Professor Bob Morgan spoke about how many of our indigenous communities were like war zones and that as a consequence our people display characteristics of communities traumatised by war. He indicated that such trauma had traditionally never been part of our cultural model of existence yet our people are consistently viewed as if the deficit is something inherent in us because we have not been able to neatly fit into the image of a dominant colonising society. The great illusion of the dominant top down model of the current health care system is the belief that if we create enlightened laws and policies without engaging the heart and voices of those who are recipients and portals for these laws, that a bureaucracy will deliver justice and global wellbeing and culturally safe work places for our people – the illusion that only what is held above us can lift us up. Such an approach suggests another form of paternalism and overturning of every aspect of our cultural continuity that has never delivered on health care since the colonisation of our lands and people.

The education and celebratory narrative of the true history of our people is crucial element of the delivery of culturally safe workplace; and in order to go forward we may need to go backwards and journey along the ‘ secret river of history’ that is suppressed on the very spot that this symposium is taking place as “broken promise drive”. Our workforce of Aboriginal health care workers is getting older and tired; and at times we have been set up to fight with each other. A good example of this is in the area of funding where governments encourage us to compete for funding and it can often result in lateral violence; a by-product of colonisation that has never been a part of our culture. Self –preservation is critical for the development of culturally safe workplaces for our people.

What needs to be acknowledged in order to secure the delivery of sustainable health care to our people is the need to accommodate into health care systems, a culturally identifiable work space for Aboriginal and Torres Strait Islander health workers. Such a space would recognise and respect the shifting cultural paradigms and pedagogical modality that ATSI people need to traverse in the delivery of their work. Such spaces are lucidly identified by the paradigm shift between the metaphor of the clock that drives western Health Care Services in a top down linear chain of command; and the metaphor of the compass which is the barometer of our people’s cultural wellbeing and pedagogically recognised in practice by its ability to move in a circular motion in the direction of immediate need. The professional paradigm of the compass lives in direct contact with the present that recognises the importance of ‘yarning and that our people like to tell stories about their health condition’ and that the needle of the compass can ‘fly anywhere’ where the need requires it to experience time in circular motions. It is not time focused in a linear structural sense but fluid and present.

It was also noted that rather than working in partnership and respect for the other across different cultural paradigms that are not necessarily mutually exclusive, Aboriginal health workers were often viewed by management through a guest paradigm: outsiders whose skills were not fully valued.

It was suggested that Health Care Services struggle to meet the needs of our people in this country precisely because they insist on a delivery of service which refuses to move outside the cultural control of the monolithic single modality of ‘the clock’. Such systemic naiveness has not recognised and factored into its practice the mutual value of the indigenous pedagogy of the ‘compass’ in the delivery of health care service through a deeper more respectful understanding and support of its Aboriginal Health Workers.

Ms. Jenny Poelina, Chairperson, NATSIHWA also emphasised that the delivery of Aboriginal Wellbeing cannot occur without the validation of Aboriginal Health care workers. Their roles are framed through personal domains not only through primary health care delivery that recognise the pivotal nature of a culturally safe Aboriginal service which emanates out of a close interconnected association with the local community. She stressed it is this local knowledge and connectedness from the ground up that provides valuable insight into the intractable issue of the poor health of our First Nations people; and that many bureaucratic health services struggle to imbue into their systemic frameworks failing to respect the invaluable skills Aboriginal Health care workers have in alleviating the horrific health of our indigenous Australians.

Speaker1:  Closing the Gap in Indigenous Health –Impediments to Change Positive Health: Dr. Jeff McMullen

  ‘Other people would drive along a bush road looking out the window of a car, but First Nations' minds embraced almost nothing of what their flickering eyes saw ~`Riders in the Chariot'  Patrick White

‘Aboriginal and Torres Strait Islander people will work with others who offer support if Government and other organisations show enough respect and common sense to listen carefully to what is actually happening in these communities.’        ~Jeff Mc Mullen

Preface: [Prof. Bob Morgan] The context of our Aboriginal people across so many indicators of wellbeing is that they are ‘just surviving’ with no opportunity to celebrate life. We may have spoken of the ‘stolen generation’ but now we have the ‘abandoned generation’. It is necessary that ‘Beacons of Hope’ exist that brings back from despair and reconnect us with the struggle to liberate our people from the ‘mind forged manacles’ of paternalism that has marked our contact history. One such beacon is Jeff McMullen.

‘The passing of a colonial mentality is a gradual and complex process, with the most visible and apparent injustices being dealt with first…But beyond the political and social changes we will need to achieve if we are to believe in ourselves as a postcolonial society, are a new set of changes, with different challenges and opportunities for growth. The next wave of postcolonial protest will expose the metaphysical and spiritual injustices of colonialism…’ ~ Dr. David Tacey La Trobe University Re-Enchantment p.81

Dr. Jeff McMullen began by stating that the day will come when we are a Human Family sharing in each other’s wellbeing; but only if we awaken to a longer more abiding, deeper knowledge where we listen more intently and empty our heads to accommodate the beauty of the other – that ancestral human knowledge of our Aboriginal people.

Why are our Aboriginal people the oldest living culture? Is this not what defines us as Australians - this ancestral human knowledge ? The wellbeing of Aboriginal and Torres Strait Islander people is the single most important test of whether Australia ever becomes a great nation. At the beginning of the 21st century we still seem unable to abandon the mistaken government paternalism of the 18th , 19th and 20th centuries.  Unless we begin to listen deeply and empty our heads of  paternal defaults of a colonial mission mentality we will never see the wisdom of the first people of this land as mutually beneficial living culture, only as Mick Dodson notes a problem to be solved.

Jeff McMullen punctuated his words with a series of reflective rhetorical questions that functioned to create moments of expansive silent stillness in the mind of the listener deconstructing what constitutes our Australianness as a Nation. For example he posed the question:  Why is there such an intact system of knowledge in our ancestral Aboriginal and Torres Strait Islander people ?  Moreover he connected this with the need to reflect on what makes us all  Australian. The possible answers to this question, he also suggested, could only emerge through a movement  deep within ourselves where we can absorb other’s stories. Furthermore he suggested that such a movement is of itself, a sign of great intellectual strength – the ability to grasp within the complexity of life the interconnected things that make people sick.

1.Cultural Safety implies an emptying our heads of the “mind forged manacles” of the past and that prison called assimilation. It requires open hearts and a great intellect to listen to Aboriginal Elders and organisations who can tell us what is going wrong and why the mainstream services do not reach their people. Rather than allowing for self-determination to take place in open dialogue with local communities Aboriginal and Torres Strait Islander people are made to struggle with a myriad of agencies that still want to dispossess, disempower and disrespect them ; and then they wonder why they walk away and become silent.

Real empowerment and safety for our First Nations people will only occur once it is recognised that sovereignty has never been ceded to the Australian Government and our constitution is revisioned ,from the perspective of the first Australians ,to recognise that in every current directive is a racist assimilation framework that when systems fail blames the client in relationship to ATSI health and education. This is the entrenched colonial default system still at work in the bureaucratic leadership of this country and its constitution.

What First Nations people have turned away from is the existential suffering and exacerbated trauma caused by the hollow words of government and the imposition of policy that is abstractly removed and disconnected from the reality of Aboriginal lives and experience on the ground.

The rhetoric of government is still framed with the old assimilation discourse and thinking: “We have a policy which will make you better if you become more like us”.

2. Jeff McMullen then went on to suggest that if we break down the current ‘Closing the Gap’ initiative what lies behind it is an attempt to frame in policy how Aboriginal men and women have been neglectful while ignoring the very national ideals we have as part of our own constructed self-image as egalitarian, fair minded and fundamentally equal. What we observe as Aboriginal people repeatedly is the hollow approach of government policy and over administration of our people that has served to magnify the gaps and profoundly ignore the voices crying out for help and self-determination , causing deeper more ingrained sensations of distress , alienation and despair.

Yet again and again, we ask First Nations people to ‘trust us’ with the delivery of basic human rights but are time and time again not listening as we continue to return with policy wrapped in the same old ‘assimilationist framework’ where we purport to have the answers. This is not only overly simplistic framework but also an insulting approach that smears Aboriginal people epithets such as a “failed culture” , “dysfunctional people” and “failed parents” ; all delivered through official policy and rhetoric.

 ‘How dare we suggest we are closing the gap!’

To give some measure of the pain and loss experienced within our Indigenous communities ,suicide which prior to colonisation was not known in ATSI people’s culture…  even just twenty years ago Indigenous suicide rates were the same as for all Australians. Today Indigenous youth suicide and self-harm have reached crisis proportions in many but not all communities… In the Northern Territory for example, the percentage of all age Indigenous suicide has increased from 5% of total suicides in 1991 to 50% of the total in 2010. The most alarming increase, however is among young Indigenous people aged 10 to 24. Indigenous youth suicide increases from 10% of the total in 1991 to 80% of the total in 2010.                                ~ Jeff McMullen from his unpublished paper ‘The Future of the Family’(2013)

3. He further stressed that we, the non-Indigenous population, need to make ourselves accountable for delivering the care and mechanisms of self-determination through partnerships and true connection with our ATSI people that allows for preventative health measures to emerge and address the generational effects of dispossession, disempowerment and disrespect.

All Australians, including all Governments, should be asking themselves , why do we go on doing the same things when clearly the despair and loss of hope is growing worse in so many communities?

Open hearts can not emerge from the distance of Canberra. ‘Closing the Gap’ indicators can only manifest into positive outcomes if we begin to put ourselves in the shoes of Aboriginal people. We have failed at the beginning of the 21st century to give our ATSI elders the proper respect and the proper care they deserve as the custodians of this land: Many are  near blind, suffering from renal illnesses and still blighted with infectious diseases that have disappeared from our cosmopolitan cities. Quite unforgivably there is no clear plan or understanding from Government that makes these old people feel part of our nation. Even more devastatingly young Aboriginal children now feel the same sense of abandonment and alienation, with horrendous rates of youth suicide and juvenile incarceration. With a profound sense of pathos McMullen noted that from the gaze of a child it is not getting better , it is getting worse.     

Where are we now? In the period we find ourselves something terrible has happened; Canberra and Darwin have not listened.

With indigenous youth suicide at epidemic levels in this country, this contagion that was prior to colonisation alien to Indigenous culture has at the first decade of the 21st century risen exponentially. This has all come out of a profound period of intervention ,dispossession and disrespect of Aboriginal people where the old  mission mentality  still is alive in Government and the disposal of human rights.

Q. “How do you fit into a country that is doing this to you – (and your young people) – putting you back in the YARD!…We are not talking about the madness of the past but the cruelty of today.”                                      [Jeff McMullen]

 4.This is still a period of oppressive paternalistic policy through the ongoing removal of children, incarceration, poor nutrition and inadequate housing.  All these indicators of increased wellbeing have got worse during this period of oppression, replicating the mindsets and same misguided logic of the “Stolen Generation”. Of the 40,000 Australian children in out of home care over 1/3rd are ATSI children and the majority do not end up in an Indigenous family. Moreover 66% of all Indigenous children in the Northern Territory are not living with their extended family.

Q. How do these children remain connected with their family and culture in ways that help them feel a sense of being SOMEBODY? How do they explore the Culture of their community, the life force that orients them towards a sense of place, a sense of identity and a sense of purpose?

Trapped in this liminal space between Aboriginal heritage and the void of disorientation that is the market place, First Nations are left to experience visceral removal from their Aboriginal Culture; mental illness and depression become a river of sickness flowing onto other generations.  The profound disorientation Aboriginal and Torres Strait Islander youth experience within contemporary Australia creates a ‘sickness of the heart’.

The pain of the ‘Stolen Generation’ is still washing through this generation but now combined with the ramifications of youth suicide; ongoing child removal; and the deepening trauma of a neo- liberal war on culture that displays a striking ignorance of an Aboriginal way of seeing and understanding how this overwhelming sadness descended over so many people.

5.This overwhelming and ongoing pattern of government oppression and disempowerment is further held in the orwellian sounding “STRONGER FUTURES” social policy for Indigenous people in the Northern Territory. Again it exacerbates disempowerment by refusing treat unemployment and poverty as an  Aboriginal problem  and in no way connected to national neglect of equity of life chances and postcolonial paternalism that says  that another dose of this will be good for you – just stay with us. It is racism in its most dangerous form to continually perpetuate deficit theories that push the blame onto victims, by stereotyping Indigenous people and their Culture as the cause of their plight.

Federal ministers would be reluctant to impose such measures on their own families yet they are impose profoundly discriminatory policies on ATSI people who within the political and social landscape of Australia have been framed in a very different way to the rest of the Australian population. Government actions and policy seem to function in a way that dismantles the foundations of common law when they remove the obligations of basic human rights from ATSI people. The Anti-Discrimination Act has been suspended three times from the Australian Constitution and each time is has involved the Indigenous community of Australia! [  Native Title ; the Hindmarsh Bridge Debate ; the NT Intervention ] All this ‘social engineering’ has taken place while the Australian Government and both major political parties declare  with studied sincerity that they seek bi-partisan agreement to improve the health and wellbeing of Indigenous Australians.

Jeff McMullen went on to stress that there has been no strategy that has held governments accountable as our parliamentary leaders continue to behave in ways that are contemptuous of ATSI human rights. He further suggested that this country has never been serious about investing in preventative health care that shifts investment and control onto the Indigenous community. [Prof. Fred McConnell.]

Associate professor Fred McConnell , Medical Director at  Sunrise Health ,  Katherine ,says many Aboriginal people have the capacity to become doctors, but the rigid nature of the current system makes it almost impossible.

"I don't think that we can drop the requirements, and I don't think we drop the standards, but we look at what are the essentials rather than what are the artificially imposed barriers."

Behind the rhetoric is a deeper darker more treacherous mindset that perpetuates the trauma and suffering of Indigenous people. We have not ‘closed the gap’ nor will we halt the downward slide of diminishing returns in Aboriginal health if we do not address the immeasurable effects of someone who has no control over their lives. Generations of government have ignored global evidence and by also ignoring conciliatory connections on the ground, we as a nation ignore the true visible indicators of wellbeing. These are the strength in unity of purpose that recognises that future wellbeing lies in self-determination and engagement with the stories of Indigenous people about the threats they face in a postcolonial society and what has caused , and continues to cause their sickness.

Neo –liberal policies have currently infected both parties that ignore these deep seated connections with Indigenous people and the delivery of health and education services. What they fail to recognise is that social engineering of people does not work; and the evidence is devastatingly evident. It is the deafness of the system that lies at the heart of effective reform. What is needed is systematic reform that requires non-Indigenous Australians to empty their heads of the assumptions that create walls of silence. Until we really listen to the needs of Indigenous people through the self-reflexive framework of  cultural safety paradigms  we will not begin to make lasting inroads into the delivery of health car and the chronic statistics that inform Indigenous health.

Speaker 2 Dianne Wepa -

Cultural Safety, The New Zealand Maori Experience

Dianne Wepa, in summarising the relevant historical context of New Zealand and its development and implementation of Cultural Safety in Nursing Education, foregrounded the critical importance of the Treaty of Waitangi, signed in 1840, as providing the framework for its progression. The specific advent of Cultural Safety evolved from the late 1980s against a backdrop of bicultural development and was born from the pain of the Maori experience of poor health care. Dianne Wepa explained that the fundamental principle underlying Cultural Safety in the healthcare context is a change of emphasis which acknowledges the shifting power from the healthcare worker which in the main is nurses to those receiving care. Once this transfer of power has occurred the recipients of care are empowered to define culturally safe practice. In other words, the ‘lived experience’ of patients determines whether or not a nurse is safe to attend to their cultural needs. This is where autonomy is given to the groups with the highest risk, and cultural safety is aligned with this preposition. Irihapeti Ramsden, a Maori registered nurse with an educational and anthropology background together with the New Zealand Nursing Council developed this term for inclusion in the undergraduate nursing curriculum. The emphasis on safety was viewed as an essential part of nursing discourse so its incorporation signalled the Council’s commitment to furthering New Zealand’s nursing education. One of the markers that make the concept ‘special’ is the use of the word safety. The language around the concept’s development is fascinating as safety aligns the term with other aspects of safety such as legal and ethical safety as opposed to words such as awareness, sensitivity and appropriateness.

Wepa acknowledged that the problem with educating nurses to be mindful of cultural differences was that the notions of difference were always set against presumed dominant cultural norms and this practice tended to reinforce ideas about ‘us and them’, ‘normal and different’, ‘typical and other’. As a result it became important to define cultural safety as distinct from concepts of cultural sensitivity and cultural awareness. As such, definitions of each of these terms were articulated. Cultural safety is an outcome of nursing and midwifery education that enables safe service to be defined by those who receive the service; cultural sensitivity alerts students to the legitimacy of difference and begins a process of self-exploration as the powerful bearers of their own life experience and realities and the impact this may have on others and cultural awareness is a beginning step toward understanding that there is difference. Central to the difference between cultural safety and cultural sensitivity and awareness is that cultural safety transitioned from meeting the ethno-specific needs of Maori towards a more generalised notion of culture and working with difference. It required educators to become responsible for ensuring an understanding of the impact of deeper, complex and more intensely felt attitudes and also acknowledging that learning may take place over a total lifetime and is not confined to a three-year programme.

The Nursing Council of New Zealand has established four principles of cultural safety for registered nurses, Principle One states that cultural safety aims to improve the health status of New Zealanders and applies to all relationships; Principle Two states that cultural safety aims to enhance the delivery of health and disability services through a culturally safe nursing workforce; Principle Three states that cultural safety is broad in its application and Principle Four states that cultural safety has a close focus on understanding the impact of the nurse as a bearer of his/her own culture, history, attitudes and life experiences and the response other people make to these factors. Additionally the National Aboriginal Health Organization’s Cultural Competency & Safety Guide for Health Care Administrators, Providers & Educators have embedded guidelines for the practice of cultural safety. It is an evolving and living document which seeks to make the distinction between transcultural or multicultural care and providers of health care stress that cultural safety is regardful of difference, that cultural safety is considered an outcome of culturally competent care and that the integration of cultural safety into the domains of the health service and health education is key. Essentially cultural safety seeks to provide an environment wherein patients engage with the service and are not passive in the health care relationship.

The Takarangi Competency Framework is a significant example of cultural safety in practice.

It acknowledges that an important component of competence is knowledge. For many Māori, the origins of knowledge and its transfer comes from the story of the ascension to the heavens for the three baskets of knowledge. Often the story of the journey only concentrates on the knowledge acquired, however the story is also very much about learning. It reminds us that competence is the convergence of knowledge and practice. The Takarangi Competency Framework developed for mental health practitioners focuses on demonstrated practice rather than just knowledge. It provides for the aspiration to excel in practice, to utilise Māori values, beliefs and experiences with therapeutic intent to not only improve access to and retention in services but to contribute to positive outcomes. The framework does not identify a minimum standard, but instead identifies a standard of excellence against which to measure practitioner competence. There are specific competencies within the framework that acknowledge cultural knowledge especially for Maori practitioners so that their world view can be acknowledged when working with Maori. This aspect of cultural competence can sometimes be overlooked so this framework acknowledges the diverse world views that practitioners also bring to the table when working with people that are culturally similar and culturally different.

 In continuing her explanation of cultural safety Dianne Wepa states that we must be mindful that people can become relativistic in their viewpoints on culture competence and sit on the fence. She advises that cultural safety moves beyond relativism and requires the provider of a health service to commit to implementing change for the benefit of the end user. In her role as as an indigenous educator she reveals that she is forever mindful that it was the pain of the Maori experience of poor health that provided the catalyst for cultural safety. As such, one of the challenges today is to consider the tensions that exist between a broad based approach to cultural safety, where Maori may compete for cultural space with other cultural groups, and a Treaty based approach where Maori stories that have never been heard before are equally shared and celebrated. She argues that it is important to consider where we position ourselves on this continuum. Is it broad based to cater for all cultures or do you take a disparity approach for want of another term where Maori are consistently featuring with the worst health statistics in New Zealand? With the current government in New Zealand there is a fear of talking about Maori ill health and the Treaty of Waitangi so the language now is about disparity. So disparity and cultural safety become 2 sides of the same coin. She warns us in Australia to watch this space as the language of disparity may become introduced here and also concludes with a Maori proverb to encourage partnership and shared vision in this important venture of exploring and practicing cultural safety – for the benefit of all.

Whakatauki / proverb

Nahau te rourou

Naku te rourou

Ka ora ai te manuhiri

Special Guest Speaker: Chronic and Infectious Diseases [Causes of disease in the Australian Indigenous and non-Indigenous population] Dr Garry Egger, epidemiologist and behavioural biologist.                                                 [ part 1 ]

1.Australian health patterns

 Contemporary Epidemics

·     Smoking

·     Fitness

·     Obesity [emerged in concerning levels during 1980s]

·     Suicide

·     Obsessive compulsive disorders

·     Anxiety and panic attacks

 In Australia and most of the developed world there has been a dramatic epidemiological shift at the end of the 20th century from infectious disease to chronic diseases. Within this spectrum Dr. Garry Eggar noticed alarming levels of Obesity among Indigenous and non-Indigenous males in the 1980s that led to his award winning GUT BUSTERS program  [documented in The Bulletin, 1991]

Moreover Dr. Eggar noted that what has happened to health trends at the beginning of the 21st century is that there has been a shift from an era of infectious diseases to one of chronic diseases. This shift is what is known as an epidemiological transition and is most evident in the population of emerging industrial giants such as China.

2.Lifestyle vs. environmental socio –cultural factors

What is of major concern among Australian Indigenous peoples is that their populations are suffering not only from chronic diseases but also from infectious diseases that are virtually non-existent in the rest of the population. The World Health Organisation  ranked the health of Indigenous Australians as 8th amongst the Pacific Nations ; and this within the wealthiest nation in the Pacific. Significantly he emphasised critical differences in the cause of ill health between indigenous and non-indigenous Australians. The origins of non-indigenous health was profoundly linked to life style and middle class attitudes to affluence; while indigenous health was profoundly environmentally based and affected by   socio – cultural factors.

Moreover there has been a progression of certain diseases at the end of the 20th century within First Nations Australians such as ;

·     Heart disease

·     Various Cancers

·     Renal Failure

·     Diabetes

If we initially look at the proximal causes [immediate] of the rising occurrence of these diseases in our Indigenous people we can easily identify causes such as  diet, lack of exercise, smoking , lack of optimum sleep, poor human relationships but people do things such as smoke for various reasons and this brings us back to observing the  cause of a cause  such as peer pressure , socio-cultural attitudes and opportunity afforded for such behaviours. Beneath this there is another possibly final cause: the modern society within which we live and the burgeoning population growth. Recent studies are revealing that our consumption rates of energy and non-renewable energy sources such as coal are the major cause of ill health in the modern world and profoundly linked to lifestyle toxicity.

3.Lifestyle Medicine & Chronic Pain

Dr Egger then went on to suggest a radical shift in the approach to health in the 21st century towards lifestyle medicine.  Such an approach lies somewhere between clinical medicine and public health. Significantly he advocates that governments can not bring about this shift in health care rather somewhere in between government policy and primary health care you need a cultural sensitivity that can only be administered through bodies such as NATSIHWA and the provision of Cultural Practice Development (CDP??) courses for doctors and pre-service training for nurses that acknowledges the role of Aboriginal Health Workers who are not to be viewed as invited guests but critical in ‘lifestyle medicine’ approaches to health.

As a final comment during this first short session with Dr Garry Egger it was also emphasised that issues surrounding the growth in chronic pain associated with mood shifts were seminally related to the way people live their lives. Chronic pain in particular has strong associations with lifestyle, sleep patterns and the drugs we consume for relief. What he is advocating is a movement towards increased CDP workshops on the critical role of AHW in the delivery of lifestyle medicine. When people lose control of their own health what emerges is a classical conditioning of the human being with practices set in place that are uncritically absorbed. A new advocacy role needs to be taken inside this model if it does not fit with the policy of an overriding system or organisational structure.

[ part 2] First Nation Health Patterns & Group Visits

1.Chronic Disease

Chronic disease has now replaced infectious diseases as the main threat to life for the general population in Australia but this is not the full story for the Aboriginal & Torres Strait Islander population.

Q. What are the underlying factors for chronic disease?

1.    The underlying factors hint at lifestyle as the cure for chronic disease

2.    Infectious diseases were not common after about the mid 19th century and the discovery of bacteria/ viruses and germ theory which was able to combat the problem of infectious diseases epidemics.

3.    CHRONIC DISEASE by contrast came into being via individual silos by specific behaviours that do not necessitate any underlying pathology. For example OBESEGENIC environments make you fat via anthropogenes:   man made chronic conditions /diseases.

4.    What differentiates chronic disease is that it cannot, like an infectious disease, be treated on a 1-1 basis. Rather the eradication of chronic disease is connected with changing lifestyle and socio-cultural shifts in a community.

Dr Egger also spoke of GROUP PEOPLE VISITS where 10-15 people suffering from the same chronic disease meet in a doctor’s rooms in sessions that involve

* no disrobing * and confidentiality agreements. Such group therapy visits can involve not only the doctor but also a Health Worker plus a facilitator. The aim is to encourage everyone to talk in a culturally safe space where peer support in changing one’s lifestyle is made available. This could be an ideal model for Aboriginal Health Workers to engage the local community in issues of lifestyle change. [ currently possible under item 23 of the Medicare cover]

He suggested the AHW is the crucial ingredient in these group sessions in part replacing individual consultations that are often hard to obtain as many clinics are overloaded. Group meetings can easily allocated in clinics where every week at a set time homogeneous groups such as  Diabetics, Heart Disease patients etc. come together. These group visits represent platforms from which medical staff and allied professionals can build trust with local communities as 70% of all disease presented to primary health care is chronic yet very little is currently been done in the delivery of health service support for chronic disease.

Dr Egger suggested that the evolution of such  group visits  goes to the core of cultural safety issues in that they have the potential to engage indigenous communities on several levels:

• The sharing of information
• Education through group dynamics and exchange of life experiences that impact on chronic disease
• Personal support from local community
• Encourage patients to stay focused on life changing shifts that may be necessary through emotional connection to the group
• Can alleviate feelings of alienation when confronting consequences of chronic disease
• Direct contact with positive preventative role modelling and empathy creates immediate sense of being supported and enabling of individuals to follow suit.

Finally, it is the efficacy of group dynamics and time management that Dr Edgger saw as the greatest benefit in the treatment and alleviation of chronic disease.

Day3: Theme ~ Beyond Rhetoric [27/3/2013] :Toward a Cultural Safety draft framework.

Review: Aboriginal People are at the beginning of the 21st century are still trying to give meaning and purpose to something that has troubled us and given us ‘trouble in mind’:the poor health of our people and the poor delivery of health care services.  Within the framework and purpose of this symposium this relates to the need to clarify distinctions between cultural awareness, cultural competency and cultural safety. A worldwide literature review has revealed a paradigm shift in the consciousness of health care workers that it has been in existence in New Zealand for almost 25 years where cultural safety has replaced the concept of cultural awareness.

Cultural safety frameworks are potentially self –reflective and transformative , beyond the skills based approaches of cultural awareness and cultural competency programs. These may form starting points in the process of raising health care worker’s sensitivity to the nature of ‘culture’ but they do not ensure cultural safety. The New Zealand model tells us that indigenous health care workers and clients wanted to move beyond models of cultural awareness towards much deeper connections with their culture that empower the aboriginal health care worker and aboriginal clients.

Significantly cultural safety frameworks, such as the New Zealand model , put the onus on systemic self-reflection and the ongoing limitations of an organisations own culture as viewed by research ethics. There is a shift in rhetoric away from the failings of the Aboriginal health care worker or client towards two way self-reflection and systemic structural analysis of the aboriginal health care worker’s environment of employment as one in which both the health care worker and client feel safe, protected and able to deliver and receive health care in supportive and trusted surroundings.

Health services should consider whether they are appropriately enabling their Aboriginal and Torres Strait Islander Health Worker workforce to help improve health outcomes to Aboriginal and Torres Strait Islander people. [Growing Our Future: Final Report,2012;p.102]

The literature review also revealed, through the work of Dean [2001], a degree of scepticism about the depth with which stand alone cultural awareness and cultural competency programs influenced real systemic change in the treatment and reception of Aboriginal Health Care workers within the health care industry. What was deemed more significant,as a transformative element of change and cultural experience of safe practice, was a raised awareness of the lack in one’s own cultural ethics through ongoing processes of learning and self-reflection by systems of health care delivery. Thus,what the literature in summary revealed was a need to clarify cultural safety as distinct from cultural awareness.

 Within this framework cultural safety is not arguing for an omission of cultural awareness or competency protocols/skills based on learning but rather represents a deepening and enriching of the process towards a practice of cultural interdependence.

Issues of distinctions

Different jurisdictions within the health care industry display different interpretations of the delivery of their service to clients. Nevertheless culturally safety in its human sweep has the potential to become a framework for all organisations and their various jurisdictions, auditing the manner in which they deliver a service.

 The development of a cultural audit that provides the tools to measure levels of cultural safety within a system will further help advance the framework as a national compliance, possibly through the Occupational Health and Safety legislation.

A culturally safe health environment can not begin to emerge without the engagement of Aboriginal and Torres Strait Islander Health Care Workers in the process of self-reflection about what has occurred to them and their life chances how they are culturally positioned in an orgnisation. As Clark Scott, CEO of NATSIHWA notes ,  Cultural Safety frameworks can not be a complete package without the reflective self-determination of Aboriginal and Torres Strait Health care workers in the delivery of culturally safe primary health care.

Speaker 1:  The Need for Cultural Safety  [Mr Pat Maher delivered by Zell Dodd, Project Manager Health Workforce Australia]

Health Workers Australia [HWA] in its final report of the Aboriginal and Torres Strait Islander Health Worker Project ,  Growing Our Future [May,2012] , recognised that there still existed significant barriers in the delivery of health care services and the treatment of the First Nations work force. A core contributing factor that the report recognises, is the lack of access to culturally safe work places and culturally safe primary health services. HWA recognises that Aboriginal people should expect to receive the same level of health care as the rest of the nation in an environment that culturally understands and listens to their needs.

What is evident is that the contribution of ATSI Health Workers make in improving access to the delivery of culturally safe comprehensive health care is not well understood or recognised across a range of systems and health organisations, including policy makers, employers and other health professionals.

The case for a culturally safe workforce has reached a critical mass as the substantial gap between the health outcomes of First Nations people and other Australians continues to increase. What constitutes a culturally safe work environment is now well documented as , “The effective care of a person/family from another culture by a health care provider who has undertaken a process of reflection on their own cultural identity and recognises the impact of the health care professional’s culture on their practice. Unsafe cultural practice is any action which diminishes, demeans or disempowers the cultural identity and well-being of an individual.”(The Nursing Council of New Zealand, 2002)

Health services need to internally reflect and review whether they are appropriately enabling ATSIHW workforce to improve health outcomes for Aboriginal and Torres Strait Islander people. Culturally unsafe health care worker environments lie at the heart of high turn over rates in Aboriginal and Torres Strait Islander staff. A key finding of the report was a misconception of the ATSI Health Worker and issues of “cultural respect” defined as the “recognition, protection and continued advancement of the inherent rights , cultures and traditions of Aboriginal and Torres Strait Islander Peoples”.[Australian Health Ministers’ Advisory Council, 2004]

Priorities aiming to increase the number and retention of Aboriginal and Torres Strait Islander people in the health workforce ,include the need to facilitate clarity of a ATSI Health Worker’s role in culturally safe environments while equipping all health care workers with local knowledge and history of indigenous people. A common factor recognised in successfully increasing the mainstream health workforce’s knowledge of ATSI health needs and culturally safe engagement, was the investment of a genuine amount time and effort in reflective transformative training beyond skills based competency achievements.

It was recognised that cultural awareness training, as an initial foundation of culturally safe environments, is important at the point of staff orientation but culturally safety requires an ongoing engagement with power relations that recognises culture to be a dynamic entity requiring constant revisions of one’s own behaviour at an individual and systemic level that empowers ATSI Health Workers in collaborative and mutually beneficial ways.

 In an attempt to address these findings , Health Workers Australia is currently moving in the direction of:

• Up-skilling and increasing the number of Aboriginal and Torres Strait Islander health workers
• Developing  an Aboriginal and Torres Strait Islander health curriculum framework
• Developing a multimedia resource package https://www.youtube.com/watch?v=SU1l5E-snBQ

2.Toward the development of an Aboriginal and Torres Strait Islander Cultural safety practice framework [Breakout GROUPS]

Cultural Safety is a call for ongoing sustainable safe partnerships and activities that help recruit and retain ATSI health workers across all sectors of the health sector. It was actively recognised that a Culturally Safe Framework could not be effective if it fails to acknowledge cultural self –determinants in the work place. The challenge that remains is how to embed indigenous pedagogy into an effective health care system. The tension many ATSI Health Care Workers feel is one of cultural identity and ongoing self-identification of culture in often unaccommodating contexts.

Culturally safe practices take us beyond simple cultural awareness accredited competencies and ask the practitioner in any community to understand not only contact history but also the consequences in their locality of colonisation through  deep listening and monitoring of power relations that can hinder the provision of service to local Indigenous communities. It references diversity competence.  That is the capacity to deal well with diverse peoples and diverse situations. It should not imply having any particular cultural pre-knowledge of any kind, except of ones own cultural biases.

It also recognises that custodial referenced leadership by Aboriginal and Torres Strait Islander people in the workforce, which is culturally framed to accommodate local context and history, as a necessary advancement that needed to be developed emphasising connection to land, as central to any culturally safe framework and rights for Indigenous Australians.

Currently there is no mechanism that make systems culturally accountable even though every health service has a mandate to advance “cultural awareness”. What is possibly required is a review of the Occupational Health and Safety legislation where a cultural safety audit may be inserted under its auspice to make organizations much more accountable and cultural safety a measurable outcome. The first step towards national legislation will need to be an active document that engages different stake holders such as the Director General of Health, NATSIHWA and health jurisdictions of the current sate based OHS legislations.

A Skeleton framework for cultural safety: Where we began- sitting strongly - listening deeply and seeing more clearly.

Summary of three (3) BREAK OUT GROUPS:

Level1: Domains ~ represent broad areas of practice that all Health Workers will be likely required to work within to ensure spaces of employment that are culturally safe spaces.

POTENTIAL DOMAINS:

1. Understand that cultural safety takes the emphasis away from categories of difference to individuals that have unique culture
2. Practicing bi-cultural partnerships in the workplace that are caring and respectful of the qualities of the other.
3. Strength –based approach recognising the unique skills that Aboriginal health care workers bring to the work place.
4. Providing an Aboriginal Custodial Leadership Strategy that recognises indigenous modalities; yarning circles; wisdom of elders; & two-way leadership.
5. Providing professional development that is culturally self-reflective and recognises different skills and qualifications of the workforce.
6. Implementation of Aboriginal Workforce Strategies.
7. Systemic self-reflection of what constitutes culturally safe work environments that includes the record of case studies of Aboriginal health care workers experiences.
8. Developing physical spaces that reflect the inherent values of culturally safe work environments and custodial leadership emphasising the principles and working pedagogies of Dadirri and other Aboriginal cultural practices  that enhance the delivery and quality of health care.
9. Integrating systems of professional care and respect that reflect upon the impact of local history and life chances of Aboriginal health care workers.

Level 2: Principles ~ represent values that will underpin each domain and promote ongoing internal reflection of constitutes culturally safe work practices by the workforce.

1.    Knowing and respecting history, local contexts, culture, customs and cultural ethics of Aboriginal and Torres Strait Islander Health Care Workers. While historical overviews may be provided the focus needs to be on the structural analysis and unpacking of inherent embedding of colonising practices in contemporary health and human service industries.

2.    Engaging in active listening and consulting respectfully with Aboriginal Health Care workers and community elders.

3.    Recognise the impact that personal culture has on professional practice

4.    Recognising that Aboriginal well-being in the workplace refers to more than the individual well-being of a health care worker but includes the social, emotional and cultural well-being of the whole community the carer is attached to via kinship laws.

5.    Respecting cultural diversity and different modalities of communication that inform Aboriginal and Torres Strait Islander peoples.

6.    Recognising the cultural respect occurs when the health system is a safe environment for ATSI peoples and there is an equity of outcomes that emerges out of ongoing reflection on systemic constructions of “culture” and “cultural bias” that hinders health care delivery.

1. Understanding that, if people start from unequal positions and you treat them equally all you do is entrench the inequality
2. Addressing organisational needs within the health care sector that bring about a commitment to the legitimate cultural rights, values and expectations of ATSI people and support culturally ethical practices.
3. Advocating for ongoing self- reflective practices at a systemic level recognising that the concept of cultural safety is a circular one which requires ongoing attention by individuals and health care organizations as a never ending process of relational interconnectedness, accommodation and self- reflection upon the limitations of one’s own culture.

Level 3: Elements ~ within each principle exist core elements that form part of the health care workers external practice and articulated role which functions to accommodate sustainable culturally safe work environments that enhance the delivery and quality of care to ATSI peoples.

1. Identify elders and other key stakeholders within the local community
2. Raise awareness of cultural security as a fundamental human right
3. Identify key community structures within the local context that impact on the modality of health care delivery by ATSI health workers.
4. Practicing sustainably and collegially, the implementation of culturally safe work places through the development of each for the development of all.

Further Considerations…

A ‘Cultural Safety Framework’ needs to include principles and domains which are integrated and interrogated across three (3) inter-related points of view:

a.    Individual - personal

b.     Systemic – cultural

c.    Organisational – political

• The Framework needs to have a consistent national approach –in order to reduce duplication.
• The Framework needs to be a Living to , Active Document  reflected in its language and modality as one of definitive action.
• Each principle /domain must include standards that should be signed off with clear jurisdictional responsibility by Australian Health Ministers Advisory Committee [AHMAC]
• The Framework should be linked to the corporate HR Plan of an agency; otherwise it could be viewed as a stand alone framework rather than a part of an integrated strategy for the  whole organization.  This will confirm its organisational status
• The framework needs to make clear statement(s) about who is its target audience and its purpose.
• The Framework needs to be generally inclusive to incorporate organisations that may not have any Aboriginal employees.
• In a preface or introduction to the Framework a clear statement and definition needs to be supplied which makes explicit the necessity for organisational cultural safety legislation- possibly as part of OHS legislation
• Could ‘Cultural Safety’ become part of Health Standards for Accreditation [ACHS]?
• The Framework needs to include an acknowledgement of the vital importance of proper orientation and induction of new employees re- cultural safety for all employees
• Cultural expertise should be valued, even if it sits outside formal parameters, particularly in local contexts if the principles of self-determination are to allow First Nations communities to lead the way in wellbeing and health improvement.

(Academic Team of Researchers - Prof. Morgan, Kon Kalos et al)