National Standards

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Action 1.21: Improving cultural competency

Providing a supportive environment and clear processes for the workforce to explore the cultural needs of Aboriginal and Torres Strait Islander patients can be a significant step towards the development of a safe and respectful organisation, where patients, their families and other community members can feel comfortable to engage with and receive care.

What does this mean for health service organisations?

Historically, the Australian health system has not provided safe and high-quality care to meet the needs of Aboriginal and Torres Strait Islander people.³¹ The health system in the past included segregated wards and service entrances, deliberately different (substandard) care, forced removal of newborn babies from mothers who were considered ‘not competent’ or not able to provide the ‘right upbringing’, and removal of children from home while parents were sick in hospital and failure to return these children to their parents’ care.

A study of 755 Aboriginal Victorians in 2013 reported that nearly all respondents (97%) had experienced at least one incident that they perceived as racist in the preceding 12 months.³²

Institutionalised racism is ‘the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people’.^33,34This should be seen in the context of systematic racism, which ‘operates across political, legal, economic and social systems’³⁴ and is a predeterminant of institutionalised racism. Both forms of racism result in assumptions and attitudes that lead to bias in the safety and quality of health care, and can result in inadequate care and poorer health outcomes for Aboriginal and Torres Strait Islander people.

These historical events and experiences, coupled with personal and family experiences of institutionalised racism and disrespectful communication, contribute to mistrust in the system by Aboriginal and Torres Strait Islander people and, at times, an unwillingness to engage with healthcare services at all.

A 2017 evaluation of Victorian hospitals found that Aboriginal and Torres Strait Islander people continue to experience hospitals as sites of trauma and the Aboriginal and Torres Strait Islander workforce experience dangerous levels of vicarious trauma, cultural load and isolation.^35,36

What is cultural awareness and cultural competency?

The literature considers cultural awareness and cultural competency on a continuum, contributing to a culturally safe environment that is respectful of Aboriginal and Torres Strait Islander patients and workforce.

Cultural awareness is a basic understanding that there is diversity in cultures across the population. Cultural competency extends beyond individual skills or knowledge to influence the way that a system or services operate across cultures. It is a process that requires ongoing learning.^37-39 One-off training does not create a culturally competent workforce, but could increase cultural awareness.⁴⁰ A culturally safe workforce considers power relations, cultural differences and the rights of the patient, and encourages workers to reflect on their own attitudes and beliefs.¹ Cultural respect is achieved when individuals feel safe and cultural differences are respected.^1,41

What are the benefits of taking action?

Benefits for the health service organisation include:

A whole-of-organisation and whole-of-system approach to improvements for Aboriginal and Torres Strait Islander people
Effective and appropriate communication with Aboriginal and Torres Strait Islander patients and families that minimises discrimination
Reduction in clinical variation across the patient population
Cost-effective and efficient delivery of care
Greater cultural capability, which could benefit all vulnerable or culturally and linguistically diverse patients
Increased understanding of Aboriginal and Torres Strait Islander health issues, health needs, and the complex personal experience of individuals, families and communities
Increased understanding of the diversity of Aboriginal and Torres Strait Islander communities
Reduced stress for the organisation’s Aboriginal and Torres Strait Islander workforce from a reduction in racially discriminatory practices, and subsequent reduction in their vicarious trauma, cultural load and isolation
Increased recruitment and retention of the Aboriginal and Torres Strait Islander workforce
Increased confidence of the overall workforce in interacting with Aboriginal and Torres Strait Islander patients and their families⁴²
Increased confidence and satisfaction of all employees who provide care for Aboriginal and Torres Strait Islander patients
Reduction of racism and discrimination

Benefits for the Aboriginal and Torres Strait Islander community include:

Improved patient perceptions and experiences of care within the health service organisation
Greater ability of patients and families to be involved in health care^43,44
Improved wellbeing of the Aboriginal and Torres Strait Islander workforce through the reduction of racially discriminatory practices
Increased access to the health service organisation by Aboriginal and Torres Strait Islander people
Improved equality and reduced disparity of health outcomes.

Key tasks

Use the national Cultural Respect Framework 2016–2026 for Aboriginal and Torres Strait Islander Health to develop, implement and evaluate cultural awareness and cultural competency strategies¹
Implement an ongoing professional development program of cultural awareness and cultural competency that is tailored to the needs of the local Aboriginal and Torres Strait Islander community
Evaluate the effectiveness of the cultural awareness and cultural competency strategies
Develop and maintain mechanisms to partner with Aboriginal and Torres Strait Islander communities to gain feedback on, and improve, cultural competency
Develop and implement an Aboriginal and Torres Strait Islander employment strategy that incorporates:
- training and ongoing professional development processes
- workforce support, including systems to retain employees and provide appropriate employee assistance programs
- recruitment of Aboriginal and Torres Strait Islander people to positions at all levels of the organisation
- increasing employment opportunities for Aboriginal and Torres Strait Islander leaders by establishing leadership development programs and pathways
Use continuous quality improvement processes to improve the cultural safety of the health service organisation
Incorporate into the professional development program opportunities to discuss and develop the workforce’s cultural awareness and cultural competency
Report on the effectiveness of the cultural awareness and cultural competency training to the governing body, the workforce, and the Aboriginal and Torres Strait Islander community.

Suggested strategies

Partner with local Aboriginal and Torres Strait Islander communities to guide strategies for improving the cultural competency of the workforce

Use the partnerships established as part of Action 2.13 to:

Identify strategies to increase the organisation’s cultural competency
Seek community feedback through mechanisms such as yarning circles, surveys or feedback from community representatives on the cultural safety of the organisation
In collaboration with local Aboriginal and Torres Strait Islander communities, determine the content and design of workforce training and assessment of cultural competency.

Successful implementation of this strategy will be supported by, or rely on, the following action:

Action 2.2b - The health service organisation applies the quality improvement system in the Clinical Governance Standard when implementing strategies to improve processes for partnering with consumers.

Develop and implement a cultural competency strategy

A cultural competency strategy should³⁹:

Cover the organisation’s anti-racial discrimination policy with the workforce
Provide mechanisms to support anti-racism and anti-bullying
Identify cultural awareness and cultural competency training requirements for the workforce
Include an Aboriginal and Torres Strait Islander employment strategy
Acknowledge significant cultural events, such as NAIDOC (National Aborigines and Islanders Day Observance Committee) Week
Provide access to cultural leave for the Aboriginal and Torres Strait Islander workforce
Describe how local cultural practices and beliefs (and acknowledgement of important cultural days and events) are incorporated into the organisation’s policies and processes
Support and grow the Aboriginal and Torres Strait Islander workforce at all levels of the organisation.

Successful implementation of this strategy will be supported by, or rely on, the following action:

Action 2.14 - The health service organisation works in partnership with consumers to incorporate their views and experiences into training and education for the workforce.

Develop, review and implement an ongoing program of cultural awareness and cultural competency training

Review and expand any existing training programs to:

Include appropriate input from local Aboriginal and Torres Strait Islander groups and organisations in the development and delivery of the programs
Include face-to-face learning, in small and large group exercises
Require an ongoing, multiphase approach that engages individuals over time, and supports continual learning and reflective practice
Include self-assessment of an individual’s or organisation’s cultural competency
Ensure that there are links with the organisation’s safety and quality improvement strategies, and human resources and professional development systems
Ensure adequate resource allocation
Ensure that routine reports are generated on the results of the program to fit the needs and context of specific units or roles.

Work by the National Aboriginal Community Controlled Health Organisation in 2011⁴⁵on cultural training identified the components of good practice. Good practice:

Explores pre-existing knowledge, and participants’ hopes and expectations for their learning
Explores participants’ cultural values and beliefs, and their intended or unintended participation in racism
Asks participants to reflect on their own culture, and how their cultural values and beliefs shape their behaviour and interactions
Emphasises the diversity of Aboriginal and Torres Strait Islander people
Clearly names racism in all its forms, and explores how it is present in health and everyday experiences for Aboriginal and Torres Strait Islander people
Asks and supports participants to apply what they learn directly to their work contexts
Considers what steps need to be taken at organisational, systemic and individual levels
Negotiates to assess the impact of the training at an agreed time following the exercise.

Successful implementation of this strategy will be supported by, or rely on, the following action:

Action 1.20c - The health service organisation uses its training systems to provide access to training to meet its safety and quality training needs.

Incorporate cultural awareness and cultural competency into the mandatory training program

Incorporate cultural awareness and cultural competency training into the mandatory training program.

Ensure that the cultural awareness and cultural competency training:

Is adequately resourced
Provides the workforce with dedicated time to attend
Is integrated into the routine monitoring and reporting framework
Is available to all the workforce (paid and volunteer), regardless of cultural background or level in the organisation, including the governing body, the executive and clinicians.

If appropriate, encourage participation by seeking continuous professional development points from professional bodies for participants.

Expect any students who undertake a placement in the health service organisation’s clinical units to have participated in cultural awareness and cultural competency training.

Develop, implement, monitor and evaluate an Aboriginal and Torres Strait Islander Employment Strategy

The Aboriginal and Torres Strait Islander employment strategy should:

Cover all levels of employment within the health service organisation, including leadership, governance, management, clinical, liaison and clerical roles
Aim to develop a strong Aboriginal and Torres Strait Islander workforce that can contribute a diverse range of skills, including the ability to break down barriers to access, and bring cultural perspectives that help meet the needs of Aboriginal and Torres Strait Islander people1
Incorporate strategies for recruitment and retention of the Aboriginal and Torres Strait Islander workforce, including creating employment pathways such as Aboriginal and Torres Strait Islander traineeships, cadetships and graduate development programs that offer long-term employment opportunities
Increase representation of Aboriginal and Torres Strait Islander employees in leadership roles at all levels of the organisation through initiatives such as:
- secondment and acting opportunities
- professional and leadership development
- Aboriginal and Torres Strait Islander leadership groups and networks.

Support the Aboriginal and Torres Strait Islander workforce

Members of the Aboriginal and Torres Strait Islander workforce are most effective when they are in a supportive and culturally safe work environment. Providing cultural safety for all members of the workforce involves:

Developing supportive policies and procedures, including a cultural leave policy
Acknowledging and supporting avoidance relationships – these are cultural practices that require formal avoidance between certain individuals, given their relationships to one another
Supporting employees’ cultural obligations to their families and communities
Providing access to culturally appropriate debriefing and emotional supports
Ensuring that members of the Aboriginal and Torres Strait Islander workforce are given opportunities to support each other, such as at regular meetings or Aboriginal and Torres Strait Islander forums
Providing training and support for non- Indigenous managers who supervise Aboriginal and Torres Strait Islander members of the workforce.

Successful implementation of this strategy will be supported by, or rely on, the following action:

Action 1.25a - The health service organisation has processes to support the workforce to understand and perform their roles and responsibilities for safety and quality.

Provide cultural coaching and mentoring

Establish a mentoring program for the Aboriginal and Torres Strait Islander workforce; this may involve senior members of the Aboriginal and Torres Strait Islander workforce supporting others in the organisation. In some communities, it may be appropriate to employ community members (often elders) to act as health ambassadors for Aboriginal and Torres Strait Islander patients, and cultural coaches and mentors for the health workforce.³⁸

Provide access to cultural coaching and mentoring for the non-Indigenous workforce to promote continued self-reflection on mainstream culture, and support their learning and understanding of Aboriginal and Torres Strait Islander cultures.

Successful implementation of this strategy will be supported by, or rely on, the following action:

Action 1.25a - The health service organisation has processes to support the workforce to understand and perform their roles and responsibilities for safety and quality.

Share Aboriginal and Torres Strait Islander patient experience stories

Share Aboriginal and Torres Strait Islander patient experiences with the workforce to support understanding and reflective practice.

Obtain consent from patients to use their stories.

Use stories in cultural competency training programs, in routine clinical review processes, such as governance and leadership meetings, and on other occasions, as appropriate.

Successful implementation of this strategy will be supported by, or rely on, the following action:

Action 2.11b - The health service organisation has processes so that the consumers involved in partnerships reflect the diversity of consumers who use the service or, where relevant, the local communities.

Include process and outcome indicators of cultural competency on the organisation’s dashboards

Develop, monitor and report on cultural competency indicators.

Collect and monitor information from complaints and risk management systems, and clinical data on Aboriginal and Torres Strait Islander patients.

Report to the governing body, the workforce and the community on cultural competency of the organisation.

Successful implementation of this strategy will be supported by, or rely on, the following actions:

Action 1.10b - The health service organisation uses clinical and other data collections to support risk assessments.

Action 1.9c - The health service organisation ensures that timely reports on safety and quality systems, and performance are provided to consumers and the local community.

Examples of supporting evidence

Documentation from cultural competency training and assessments
Schedule of cultural awareness and cultural competency training
Data and reports on evaluation of the cultural competency of the health service organisation
Policies, procedures or protocols that cover cultural competency
Patient experience surveys and feedback
Hospital treatment and performance outcomes such as discharge against medical advice, and employment of Aboriginal and Torres Strait Islander clinicians
Documentation from meetings at which the cultural needs of Aboriginal and Torres Strait Islander employees are discussed, or strategies to meet their needs are identified, monitored or evaluated
Position descriptions, duty statements and employment contracts that detail the roles and responsibilities of the Aboriginal and Torres Strait Islander workforce
An Aboriginal and Torres Strait Islander employment strategy
Evaluation reports or routine updates provided to the governing body on strategies to improve cultural awareness and cultural competency
Established and monitored workforce targets; these include proportions of Aboriginal and Torres Strait Islander employees in the overall organisation workforce, and in clinical and non-clinical areas of the organisation.

References

1. National Aboriginal and Torres Strait Islander Health Standing Committee of the Australian Health Ministers’ Advisory Council. Cultural respect framework 2016–2026 for Aboriginal and Torres Strait Islander health. Canberra: AHMAC; 2016.

31. Sherwood J. Colonisation – it’s bad for your health: the context of Aboriginal health. Contemp Nurse 2014;46:28–40.

32. Ferdinand A, Paradies Y, Kelaher M. Mental health impacts of racial discrimination in Victorian Aboriginal communities: the Localities Embracing and Accepting Diversity (LEAD) Experiences of Racism Survey. Melbourne: Victorian Health Promotion Foundation; 2013.

33. Home Office. The Stephen Lawrence Inquiry: report of an inquiry by Sir William Macpherson of Cluny. London: Home Office; 1999.

34. The Lowitja Institute. Systemic racism. Workshop background paper. Melbourne: The Lowitja Institute; 2016.

35. Victorian Department of Health and Human Services. Submission to the consultation for the National Safety and Quality Health Service Standards user guide for Aboriginal and Torres Strait Islander health. Melbourne: DHHS; 2017.

36. Victorian Department of Health and Human Services. Evaluation of improving cultural responsiveness of Victorian hospitals. Melbourne: DHHS; 2017.

37. Bainbridge R, McCalman J, Clifford A, Tsey K. Cultural competency in the delivery of health services for Indigenous people. Issues Paper No. 13 produced for the Closing the Gap Clearinghouse. Canberra: Australian Institute of Health and Welfare, and Melbourne: Australian Institute of Family Studies; 2015.

38. Fisher TL, Burnet DL, Huang ES, Chin MH, Cagney KA. Cultural leverage: interventions using culture to narrow racial disparities in health care. Med Care Res Rev 2007;64 (5 Suppl):243–82S.

39. Truong M, Paradies Y, Priest N. Interventions to improve cultural competency in healthcare: a systematic review of reviews. BMC Health Serv Res 2014;14:99.

40. Mooney N, Bauman A, Westwood B, Kelaher B, Tibben B, Jalaludin B. A quantitative evaluation of Aboriginal cultural awareness training in an urban health service. Aborig Isl Health Work J 2005 Jul/Aug;29(4):23–30.

41. Dwyer J, Willis E, Kelly J. Hospitals caring for rural Aboriginal patients: holding response and denial. Aust Health Rev 2014;38:546–51.

42. Perry A, Woodland L, Brunero S. eSimulation: a novel approach to enhancing cultural competence within a health care organisation. Nurse Educ Pract 2015;15:218–24.

43. Burnette L, Kickett M. ‘You are just a puppet’: Australian Aboriginal people’s experience of disempowerment when undergoing treatment for end-stage renal disease. Ren Soc Aust J 2009;5:113–8.

44. Burnette L, Kickett M. Dislocation and dialysis in Aboriginal patients with renal failure. Aborig Isl Health Work J 2009 Jul/Aug;33(4):10–3.

45. National Aboriginal Community Controlled Health Organisation. Creating the NACCHO Cultural Safety Training Standards and Assessment Process: a background paper. Canberra: NACCHO; 2011.