Cultural Safety and Communication in Healthcare

Defining Cultural Safety

• Cultural safety acknowledges barriers to effective healthcare caused by power imbalance between clinician and patient.
• It's not about learning cultural customs but about:
  • Being aware of difference
  • Decolonising practices
  • Considering power relationships
  • Implementing reflective practice
  • Allowing the patient to define a safe clinical encounter
• Health practitioners must examine their own cultural impact on clinical interactions, questioning biases, attitudes, assumptions, and stereotypes.
• Ramsden’s Cultural Safety Framework helps health professionals reflect on their role in achieving culturally safe practice.
• Curtis et al (2019) definition adopted by Australian healthcare organizations:
  • Healthcare professionals and organizations must examine their cultural impact on clinical interactions and service delivery.
  • Requires acknowledging and addressing biases, attitudes, assumptions, stereotypes, prejudices, structures, and characteristics that may affect care quality.
  • Cultural safety includes critical consciousness, ongoing self-reflection, self-awareness, and accountability for culturally safe care, as defined by patients and communities, measured by progress toward health equity.
  • Requires influencing healthcare to reduce bias and achieve equity within the workforce and working environment.

Key Elements of Cultural Safety

• Defined by care recipients, not providers.
• Healthcare professionals and organizations are responsible for creating and maintaining culturally safe spaces.
• Based on individual self-awareness and collective social accountability.
• Promoted when participants demonstrate cultural humility and respect.
• The presence and impact of intergenerational trauma due to discrimination, racism, dispossession, and humiliation must be acknowledged and redressed.

Cultural Safety and Communication

• Care in a culturally safe environment is facilitated by a shared commitment to cultural respect among all stakeholders.
• Cultural respect: "recognition, protection and continued advancement of the inherent rights, cultures and traditions of Aboriginal and Torres Strait Islander people" (Australian Health Ministers Advisory Council, 2016).
• Vision of the Cultural Respect Framework: "The Australian health system is accessible, responsive and safe for Aboriginal and Torres Strait Islander people where cultural differences and strengths are recognised and incorporated into the governance, management and delivery of health services".
• The Cultural Respect Framework is built around six domains, with communication being a key feature: "Effective communication with Aboriginal and Torres Strait Islander consumers is the foundation for the delivery of accessible, culturally responsive and safe health care".

Cultural Self and Identity

• Everyone has culture; it's part of what makes us who we are.
• Recognizing and respecting cultural diversity is important for culturally competent health practitioners, researchers, and policymakers.
• Examining one's own culture is a first step in understanding others' cultures.
• Culture is not static; beliefs and values change over time, forming new ways of viewing and living in the world.

Cultural Self in Healthcare

• Aims to provide a way of recognizing the influence of one’s own cultural identity and the culture of the Australian health care system on perceptions of Aboriginal and Torres Strait Islander peoples.
• Inequalities in Aboriginal and Torres Strait Islander health outcomes include complex intersections between culture, poverty, politics, and racism.
• Social, Cultural and Political Determinants of Health: structures of society and social conditions in which people grow, live, work and age; factors outside traditional health domains.

Kinship

• Connection to Family, Kinships and Community
• The Social and Emotional Well Being domains of connection to family and kinship, and community, refer to aspects of wellbeing that are rooted in interpersonal interaction.

Family and Kinship

• Family systems are central to Aboriginal and Torres Strait Islander societies, maintaining interconnectedness through cultural ties and reciprocal relationships.
• Milroy states: These systems locate individuals in the community and neighbouring clans within relationships of caring, sharing, obligation and reciprocity.
• The kinship system provided a secure attachment system with multiple carers.
• In contemporary society, kinship and cultural obligations can place burdens on family members; grandmothers may lack support to care for large families.
• Practitioners should understand the different language and family groups of the communities they work in.
• In traditional regions, moiety or skin group systems entail complex avoidance relationships that determine interaction between family and kin members.
• AIATSIS Map of Indigenous Australia: Represents language, social or nation groups of Aboriginal Australia.
  • Shows general locations of larger groupings, including clans, dialects or individual languages.
  • Based on published resources from the eighteenth century-1994.
  • Not intended to be exact, nor the boundaries fixed.
  • Not suitable for native title or other land claims.

Health Implications of Identification

• In April 2010, the Australian Institute of Health and Welfare (AIHW) published guidelines for collecting Indigenous status in health data sets.
• Recommended question: ‘Are you of Aboriginal or Torres Strait Islander origin?’
• Adopted by the Council of Australian Governments (COAG) to report progress against performance indicators to close the gap in health outcomes.
• The Australian Indigenous Doctors’ Association (AIDA) position statement on Aboriginal and Torres Strait Islander Patient Identification.

Cross Cultural Communication Introduction

• This module introduces cultural and communication protocols relevant in professional healthcare contexts.
• Emphasizes that cross-cultural interactions involve complex explicit and implicit exchanges that ultimately impact on the extent to which some minority group members engage with essential health services.
• According to the Department of Health Aboriginal and Torres Strait Islander Health Curriculum Framework (2016, updated 2021):
  • Aboriginal and Torres Strait Islander patients are more likely to access services where providers communicate respectfully, understand Aboriginal culture, build good relationships, and where Aboriginal or Torres Strait Islander health workers are part of the team (Durey et al., 2011; Shaouli Shahid et al., 2009; Taylor et al., 2009).
  • Health providers’ attitudes and behaviours can undermine or enable better health outcomes, expressed through communication.
• Jennings et al (2018) reported that:
  • There is no shared universal Indigenous culture or communication style, but there is a shared experience of encountering a healthcare system acting as an apparatus of colonisation and control (Eckermann et al. 2010).
  • The request by Indigenous clients to minimise the power differential is a request for the health system to demonstrate that it has changed, that it does not wish to dominate and demean, but rather respect and care for its Indigenous clients as human beings.
  • Good, caring talk can reconfigure relationships between Indigenous clients and the healthcare system.
• Sharing personal information may be useful to establish a relationship.

Practice Tips - Language and Communication

• Effective communication is the foundation for accessible, culturally responsive, and safe health care.
• Address barriers Aboriginal and Torres Strait Islander people face in accessing and receiving health care.
• Address misalignment of the mainstream health system with Aboriginal and Torres Strait Islander peoples and cultures.
• Always be aware of your local context and focus on the client’s response to you as a gauge of how comfortable they are with your attempts at relationship building.

Practice Tips

• Where possible allow a support person to accompany the client
• Recognise that not all Aboriginal and Torres Strait Islander people want to work with an Aboriginal or Torres Strait Islander Worker
• Share personal information about yourself to help establish a relationship. e.g. Where you come from and other places you may have worked with Indigenous people
• Do not expect all Aboriginal people want to share information regarding families and culture or local history
• Ensure that there are opportunities for extended family to be included in important meetings and in making important decisions
• Be aware that some Aboriginal or Torres Strait Islander people may not know their family history
• Silence should not be misunderstood and should be respected. The person may be reflecting on what you have said and may want more time to think about how to respond to a question
• In some communities, direct eye contact can be a sign of disrespect and in other communities, direct eye contact will be expected. It is important to take your lead from the Aboriginal or Torres Strait Islander person you are speaking with
• Accept that some questions may not be answered
• Have a look at maps and get to know the Aboriginal language groups in your area and the history of those language groups

Communication Protocols

• Diversity across Indigenous Nations in Australia requires health practitioners and policymakers to check suggestions with local Aboriginal and Torres Strait Islander health professionals and community members.

• Cultural communication publications often focus on Indigenous communication styles and neglect the broader field of Health communication.

• Cultural safety is a framework that may afford means to address these problems. (Warren, Bond and Hill, 2018)

• Warren, Bond and Hill (2018) state:

  • Health inequalities experienced by Aboriginal and Torres Strait Islander Australians are attributable to social and cultural determinants of health (Marmot 2011).
  • Under-utilisation of healthcare services suggests health practitioners can play a critical role in closing the gap of health inequality through improving access to healthcare (Hayman et al. 2009; Australian Institute of Health and Welfare 2013).
  • Requires health services that are not only physically and economically accessible, but culturally safe and acceptable, from remote to urban contexts (Scrimgeour and Scrimgeour 2007).
  • Culturally safety ‘is the mechanism which allows the recipient of care to say whether or not the service is safe for them to approach and use. Safety is a subjective word deliberatively chosen to give the power to the consumer’ (Ramsden 2002).

• Two key components of culturally safe healthcare communication emerged: the power of talk, and power differentials within talk.

  • The power of talk refers to the esteem in which Indigenous respondents held talk, both individually and community-wide, with health professionals as well as with each other.
  • This power was mediated by the power differentials experienced through talk, including talk that demeaned, diminished or disempowered (Eckermann et al. 2010), as well as talk that challenged or reoriented the relationships between Indigenous peoples and the health system.

Health Professional Guidelines and Codes of Conduct

• Professional standards and guidelines for the treatment and care of Aboriginal and Torres Strait Islander patients are now commonplace.
• These documents include reference to the importance of culturally safe and sensitive practice and effective communication to the improvement of health and wellbeing outcomes for Aboriginal and Torres Strait Islander peoples.
• To this end, ‘culturally appropriate’ healthcare delivery has become part of health workforce training, health curricula and professional accreditation standards (Jennings et al 2018:109)
• Indigenous Allied Health Australia (IAHA) suggests that emphasis on life-long self-reflection and new learning is more appropriate than the notion of finality that terms such as cultural competency may imply. (AIHA: 2013)
• Being culturally responsive places the onus back onto the health professional to appropriately respond to the unique attributes of the person, family or community they are working with.
• Self-reflection and reducing power differences are central to being culturally responsive; therefore making assumptions based on generalisations about a person’s ethnic, cultural or social group is unacceptable.
• Part of the challenge of becoming a culturally responsive health professionals is learning to reach beyond personal comfort zones and being able to comfortably interact and work with people, families and communities who are both similar and markedly different (AIHA:2013)

Professional Codes of Conduct and Research Guidelines for Health Care Professionals About the National Boards and AHPRA

• The 14 National Boards regulating registered health practitioners in Australia are responsible for:
  • Registering practitioners and students,
  • Setting the standards that practitioners must meet,
  • Managing complaints and concerns (notifications) about the health, conduct or performance of practitioners.
• Undergraduate psychology students are not regulated by AHPRA and are not registered.
• Psychology students are registered as provisional psychologists when they enter postgraduate training ( eg. Master of Psychology programs)
• The Australian Health Practitioner Regulation Agency (AHPRA) works in partnership with the National Boards to implement the National Registration and Accreditation Scheme, under the Health Practitioner Regulation National Law, as in force in each state and territory (the National Law).