The Cultural safety in health care for Indigenous Australians: monitoring framework is structured around three modules: Module 1 – Culturally respectful health care services; Module 2 – Patient experience of health care; and Module 3 – Access to health care services. Each of the three modules contains a number of domains, focus areas and measures, with the following structure:
Module → domain → focus area → measure
The three modules look at different dimensions of cultural safety – how health care is provided, experienced and accessed. The domains are topics within the modules; focus areas look at specific issues in the domains; and measures describe the data presented in the focus areas.
The modules and their domains are set out below.
- Treated respectfully
- Unfair treatment and cultural barriers
- Family inclusion
- Leave events
Origin and policy context
The concept of cultural safety has been around for some time, with the notion originally defined and applied in the cultural context of New Zealand. It originated there in response to the harmful effects of colonisation and the ongoing legacy of colonisation on the health and healthcare of Maori people – in particular in mainstream health care services.
A commonly accepted definition of cultural safety from the Nursing Council of New Zealand (2005:7) is the ‘effective nursing practice of a person or family from another culture, and is determined by that person or family. Unsafe cultural practice comprises any action which diminishes, demeans or disempowers the cultural identity and wellbeing of an individual.’
A distinctive feature of this definition of cultural safety is its emphasis on the provision of culturally safe health care services as defined by the end users of those services, notably, the Maori people of Aotearoa New Zealand, not by the [non-Maori] providers of care.
The National Collaboration Centre for Indigenous Health in Canada (2013) notes that culturally safe health care systems and environments are established by a continuum of building blocks:
Cultural awareness ⟹ Cultural sensitivity ⟹ Cultural competency ⟹ Cultural safety
The Centre states that cultural safety ‘…requires practitioners to be aware of their own cultural values, beliefs, attitudes and outlooks that consciously or unconsciously affect their behaviours. Certain behaviours can intentionally or unintentionally cause clients to feel accepted and safe, or rejected and unsafe. Additionally cultural safety is a systemic outcome that requires organizations to review and reflect on their own policies, procedures, and practices in order to remove barriers to appropriate care.’
In Australia, there has been increasing recognition that improving cultural safety for Aboriginal and Torres Strait Islander health care users can improve access to, and the quality of health care. This means a health system where Indigenous cultural values, strengths and differences are respected; and racism and inequity are addressed.
There are difficulties in both defining and measuring generalised concepts such as cultural respect and cultural safety. They include lack of conceptual clarity and agreement on terms, the qualitative nature of the concepts, and the diversity of Indigenous Australians and their perceptions. The Australian literature uses various definitions of cultural safety, and related concepts such as cultural respect and cultural competency, and what these mean in relation to the provision of health care.
The National Aboriginal and Torres Strait Islander Health Plan 2021–2031 (DoH 2021:52) states:
Cultural safety is about how care is provided, rather than what care is provided. It requires practitioners to deliver safe, accessible and responsive health care that is free of racism by:
- recognising and responding to the power imbalance between practitioner and patient
- reflecting on their knowledge, skills, attitudes, practising behaviours, and conscious and unconscious biases.
For the purpose of developing a monitoring framework, cultural safety is defined with reference to the experience of the Indigenous health care consumer, of the care they are given, their ability to access services and to raise concerns. Some of the essential features of cultural safety include an understanding of one’s culture; an acknowledgment of difference, and a requirement that caregivers are actively mindful and respectful of this difference; and the ability to recognise, address and prevent racism. The presence or absence of cultural safety is determined by the experience of the recipient of care and is not defined by the caregiver (AHMAC 2016).
Two important aspects of culturally safe health care across the literature are, how it is provided and how it is experienced, and these form the basis for the monitoring framework (see AHMAC 2016; CATSINAM 2014; AIDA 2021; DHHS 2016; NACCHO 2011; DoH 2015).
How health care is provided
- behaviour, attitude and culture of providers: respects and understands Indigenous culture and people
- defined with reference to the provision of care, including governance structures, policies and practices
- providers' ability to recognise, address and prevent racism at the individual and organisational levels.
How health care is experienced by Indigenous people
- feeling safe, connected to culture and cultural identity is respected
- can only be defined by those who receive health care.
The importance of cultural respect and cultural safety is outlined in Australian government documents, such as:
- Cultural Respect Framework 2016–2026 for Aboriginal and Torres Strait Islander Health
- National Aboriginal and Torres Strait Islander Health Plan 2021–2031.
- National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan 2021-2031
The health plan was developed in genuine partnership with Aboriginal and Torres Strait Islander people and reflects their key priorities. It recognises the influence of social factors and the strengths of culture as protective factors for physical, social and emotional wellbeing.
The Australian Commission on Safety and Quality in Healthcare (ACSQHC) also included six Aboriginal and Torres Strait Islander specific actions in the National Safety and Quality Health Service Standards to improve care for Aboriginal and Torres Strait Islander people in mainstream health services.
Increasing representation of Aboriginal and Torres Strait Islander people in the health workforce is a key pathway to improving cultural safety in health care. This is the focus of both the Department of Health and Aged Care’s National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan 2021-2031 and the Australian Health Practitioner Regulation Agency’s (Ahpra) National Scheme's Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020–2025.
Development of a monitoring framework
The Cultural safety in health care for Indigenous Australians: monitoring framework aims to measure progress in achieving cultural safety in the Australian health system by bringing together data related to cultural safety. Specifically, to measure progress in achieving cultural safety in the health system under the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–2023. The framework can also assist in measuring progress in achieving cultural safety under the Cultural Respect Framework which commits the Commonwealth Government, and states and territories, to embed cultural respect principles into their health systems; from developing policy and legislation, to how organisations are run, through to the planning and delivery of services.
The release of the 2020–2031 National Agreement on Closing the Gap necessitated revisions to the National Aboriginal and Torres Strait Islander Health Plan 2013–2023, in order for the Health Plan to be aligned with the objectives and timeframes of the National Agreement. Following the release of the National Aboriginal and Torres Strait Islander Health Plan 2021–2031 the Implementation Plan will be revised and a new accountability framework will be created.
In consultation with key stakeholders, including the former National Aboriginal and Torres Strait Islander Health Standing Committee and the Implementation Plan Advisory Group, this monitoring framework was developed through a review of relevant policy documents, academic literature, and potential national and state level data sources.
The framework has 3 reporting modules which each include a range of measures focussing on culturally respectful health care services, patient experience of health care among Indigenous Australians, and access to health care as an indirect measure of cultural safety.
Module 1: Culturally respectful health care services
- includes measures about how health care is delivered and whether systems and providers are aware of and responsive to Indigenous Australians' cultural needs and experiences
- largely based on the Cultural Respect Framework for Aboriginal and Torres Strait Islander Health
Module 2: Patient experience of health care
- includes measures about Indigenous Australians' experiences of health care including communication, interpersonal treatment and empowerment, and is not defined by the caregiver
- based on a literature review and research on different aspects of Indigenous Australians' views on cultural safety
Reporting against the framework
This monitoring framework brings together available national and state and territory level data to provide a picture of cultural safety in the health system. The scope of national and state and territory level data currently available are limited and further development is required to enable more comprehensive reporting. For more detail see information about data gaps in Module 1: Culturally respectful health care services, Module 2: Patient experience of health care, and Module 3: Access to health care services.
Monitoring cultural safety and cultural respect in the health system, and the impact it has on access to appropriate health care, is limited by a lack of national and state level data. This is particularly the case in relation to reporting on the policies and practices of mainstream health services, such as primary health care services.
There are also limited data on the experiences of Indigenous health care users. Most jurisdictions undertake patient experience surveys in public hospitals, but there is little data on Indigenous Australians for reporting. A high proportion of Indigenous Australians use mainstream health services, so further data developments in this area are required to allow for more comprehensive reporting across the health sector.
As data developments occur and more comprehensive data become available, the cultural safety monitoring framework will be expanded and updated.
Relevant data developments
Data development for cultural safety measures is ongoing. There are also research and developments in measurement of areas related to cultural safety, such as wellbeing and quality of life.
One such project is What Matters 2 Adults study, which aims to develop a new instrument to measure and value wellbeing dimensions that are important to Indigenous Australians (Howard et al. 2020). In 2021, the authors published findings from the qualitative component of the study, which involved 359 Aboriginal and Torres Strait Islander adults from around Australia. A thematic analysis identified 5 foundations of wellbeing: belonging and connection, holistic health, purpose and control, dignity and respect, and basic needs. These findings will inform the development of a new wellbeing measure (Garvey et al. 2021). This project is still underway.
Another example is the Mayi Kuwayu study, a national longitudinal survey of Indigenous Australians aged 16 years and above. It began in 2018 and could provide relevant data on cultural safety in the future. This survey, which was created by and for Indigenous people, focusses on the importance of culture and how it affects wellbeing, and includes a module on discrimination and racism in health care. Initial results from the study and the validity of the instrument used to measure discrimination in health care experienced by Indigenous Australians are discussed in Thurber and others (2021). There have been a number of publications released by the Mayi Kuwayu team. Links to these publications appear in the relevant domains within the monitoring framework.
Indigenous patients’ experiences of health care could be reported through Patient Reported Experience Measures (PREMs) and Patient Reported Outcome Measures (PROMs) surveys. The collection of patient-reported data through standardised PREMs and PROMs for Indigenous health care users’ needs to consider the cultural adaptability of these tools and development work is underway to address this at hospital and primary health care service level.
The National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan 2021-2031 includes the development of mechanisms to ensure that cultural safety training translates into improved experiences and outcomes for Aboriginal and Torres Strait Islander workers. The plan recognises that participation of Aboriginal and Torres Strait Islander peoples in the health workforce will promote culturally safe care and improve health outcomes for Aboriginal and Torres Strait Islander patients.
AHMAC (Australian Health Ministers’ Advisory Council) 2016. Cultural Respect Framework 2016–26 for Aboriginal and Torres Strait Islander Health: a national approach to building a culturally respectful health system. Canberra: AHMAC.
AIDA (Australian Indigenous Doctors’ Association) 2021. Position Paper: Cultural Safety. Canberra: AIDA.
CATSINaM (Congress of Aboriginal and Torres Strait Islander Nurses and Midwives) 2014. Towards a shared understanding of terms and concepts: Strengthening nursing and midwifery care of Aboriginal and Torres Strait Islander peoples. Canberra: CATSINaM.
DoH (Department of Health) 2015. Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–2023. Canberra: DoH.
DoH 2021. National Aboriginal and Torres Strait Islander Health Plan 2021–2031. Canberra: DoH.
DHHS (Department of Health and Human Services) 2016. Improving cultural responsiveness of Victorian hospitals: Final Report. Victoria: DHHS.
Garvey G, Anderson K, Gall A, Butler TL, Cunningham J, Whop LJ, Dickson M, Ratcliffe J, Cass A, Tong A, Arley B and Howard K 2021. What Matters 2 Adults (WM2Adults): Understanding the Foundations of Aboriginal and Torres Strait Islander Wellbeing18:6193. doi: 10.3390/ijerph18126193.
Howard K, Anderson A, Cunningham J, Cass A, Ratcliffe J, Whop LJ et al 2020. What Matters 2 Adults: a study protocol to develop a new preference-based wellbeing measure with Aboriginal and Torres Strait Islander adults (WM2Adults). BMC Public Health 20: 1739. doi:10.1186/s12889-020-09821-z.
NACCHO (National Aboriginal Community Controlled Health Organisation) 2011. Creating the NACCHO Cultural Safety Training Standards and Assessment Process: A background paper. Canberra: NACCHO.
National Collaborating Centre for Indigenous Health 2013. Towards Cultural Safety for Métis: An Introduction for Heath Care Providers. Canada: University of Northern British Columbia.
Nursing Council of New Zealand 2005. Guidelines for cultural safety, the treaty of Waitangi, and Maori health in nursing and midwifery education and practice. Wellington: Nursing Council of New Zealand.
Thurber KA, Walker J, Batterham PJ, Gee GC, Chapman J, Priest N et al. 2021. Developing and validating measures of self-reported everyday and healthcare discrimination for Aboriginal and Torres Strait Islander adults. International Journal of Equity in Health 10: 14. doi:10.1186/s12939-020-01351-9.