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’.33,34 This should be seen in the context of systematic racism, which ‘operates across political, legal, economic and social systems’34 and is a predeterminant of institutionalised racism. Both forms of racism result in assumptions and attitudes that lead to bias in the safety and quality of health care, and can result in inadequate care and poorer health outcomes for Aboriginal and Torres Strait Islander people.
These historical events and experiences, coupled with personal and family experiences of institutionalised racism and disrespectful communication, contribute to mistrust in the system by Aboriginal and Torres Strait Islander people and, at times, an unwillingness to engage with healthcare services at all.
A 2017 evaluation of Victorian hospitals found that Aboriginal and Torres Strait Islander people continue to experience hospitals as sites of trauma and the Aboriginal and Torres Strait Islander workforce experience dangerous levels of vicarious trauma, cultural load and isolation.35,36
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 care43,44
- Improved wellbeing of the Aboriginal and Torres Strait Islander workforce through the reduction of racially discriminatory practices
- Increased access to the health service organisation by Aboriginal and Torres Strait Islander people
- Improved equality and reduced disparity of health outcomes.
- 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.
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.
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.