1. Unity and Strength through Caring
Aboriginal and Torres Strait Islander
Higher Education Consortium
(NATSIEC) workshop
“CATSINAM, Cultural Safety & Racism”
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I would like to acknowledge the Traditional
Owners of the country we are meeting on
today, the Kaurna People, and pay my
respect to my Elders, past and present and
our future emerging generations
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The Universities Australia’s
Indigenous Strategy 2017-2020
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“Australia is home to the world’s oldest continuing
cultures. This towering achievement of Aboriginal
and Torres Strait Islander peoples in human history
is the foundation story of our country and our
national identity.”
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What is racism ?
The Macquarie Concise Dictionary (1996) defines racism like this:
1. the belief that human races have distinctive characteristics
which determine their respective cultures, usually involving the
idea that one’s own race is superior and has the right to rule or
dominate others.
2. offensive or aggressive behaviour to members of another race
stemming from such a belief.
3. a policy or system of government and society based upon it.
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Aboriginal cricket pioneer & Midwife
Faith Thomas
Sister Muriel Stanley
Sister Alison Bush
Centering the
stories of
Aboriginal
midwives in the
curriculum,
In your stories
about the
profession and
its history.
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“By deepening and enhancing the contributions of
Aboriginal and Torres Strait Islander people, universities will
expand their own contributions to:
close the gap in disadvantage;
lift the visibility of Indigenous expertise, excellence and
contributions to Australia;
acknowledge and support the rights, languages, and cultures
of Indigenous communities;
tackle racism; and
promote equal opportunity and outcomes for all Australians.
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“Institutional or structural racism can operate with a high
level of subtlety. It is frequently reproduced through
assumptions, processes and systems within institutions.
Decision making within institutions can be shaped by biases
and prejudices, of which people may not necessarily be
conscious.
“Anti-racism work must be prepared to challenge or shift
power structures within institutions. It is not sufficient to
confine anti-racism efforts to attempts to shift individual
attitudes and behaviour.”
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How many universities set KPIs for their senior executives
that focus their efforts on the work of anti-racism?
How many universities set targets around reducing their
students’ and employees’ experiences of racism, and then
measure and report upon their progress in meeting those
targets?
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Health inequities: Health conditions
Australian Health Ministers’ Advisory Council 2017,
Aboriginal and Torres Strait Islander Health
Performance Framework 2017 Report, AHMAC,
Canberra.
Chronic
respiratory
diseases
Non-
Indigenous
baseline Kidney
disease:
Stage 1
Circulatory
disease
Hyper-
tension
Diabetes in
adults
2.5 times
higher
1.5 times
higher 1.2 times
higher
3 times
higher
>3 times
higher
Kidney
disease:
Stage 4-5
5 times
higher
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Moving beyond “treating everyone
the same…”
Equity is giving everyone
what they need to be
successful
Equality is treating everyone
the same, it aims to promote
fairness but can only work if
everyone starts from the
same place and needs the
same help.
We want to move well
beyond equality to
equity and, ultimately,
to liberation
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Racism and cultural safety – realities and impacts
Reflect on your own experience with racism:
What you have witnessed?
What you have experienced?
What others have told you?
What % of Aboriginal and Torres Strait Islander Australians…
report they have experienced
racism in their personal or
professional lives?
experience racism in their personal
or professional lives?
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Some facts about racism
93% of 153 Aboriginal South Australians reported they experienced racism in both
informal and formal settings – including the health system. (Gallaher, Ziercsh, Baum,
Bentley, Palmer, Edmondson & Winslow, 2009)
In a 2011 survey of 755 Aboriginal Victorians, 97% had experienced racism in the
previous 12 months, most people multiple times, with more than 70% reported eight
or more incidents a year. (Ferdinand, Paradies and Kelaher, 2013)
Racism is a common experience for Aboriginal and Torres Strait
Islander people:
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Some facts about racism
Racism in the health system has serious consequences for health care
and health outcomes:
Indigenous patients with the same characteristics as non-Indigenous patients were a third
less likely to receive appropriate medical care across all conditions as well as specifically for
cancer and coronary procedures.
(Paradies, Trenerry, Franklin H & Guerin, 2010)
[A] Western Australian study in a rural town demonstrated that racism was clearly linked to
poorer levels of general physical and mental health, having accounted for age, gender,
employment and education.
(Larson, Gilles, Howard & Coffin, 2007)
“The evidence for negative effects on both physical and mental health from racism is solid
and undeniable.”
(Paradies, 2013, in Poche Centre Report, 2014, p.6)
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Completion rates for Aboriginal and Torres
Strait Islander nursing students
West, R, Buttner, P, Foster, K, Usher, K & Stewart, L, 2013,
Indigenous Australians' participation in pre-registration tertiary nursing
courses: A mixed methods study, Contemporary Nurse, Aug 4. [Epub
ahead of print]
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Self-reflection exercises on cultural
safety
Who has attended ‘cultural safety training’?
What understanding do you have of cultural safety?
1 = None 2 = Limited 3 = Some 4 = Fair 5 = Good
What ability do you have to explain the difference between
cultural awareness and cultural safety training?
1 = None 2 = Limited 3 = Some 4 = Fair 5 = Good
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Cultural Safety vs. Cultural
Awareness
Cultural Awareness :
Acknowledges differences
Doesn’t seek broader context or understanding
The gaze is outwards
Very limited behavior change
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What did NACCHO conclude in 2011?
“While there is a place for cultural awareness
programs, they are insufficient in terms of achieving
genuine change in Aboriginal Peoples’ experience of
health services and health outcomes.”
(NACCHO, 2010, p. 9)
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Take away: CS is ‘knowing thy self, the gaze is
inward… not outward
to challenge clichés, myths & understanding &
where they come from
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“An appreciation of the
historical context of
colonisation, the
practices of racism at
individual and
institutional levels, and
their impact on First
Nations people’s living
and wellbeing, both in
the present and past”.
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Analogy of why Aboriginal and
Torres Strait Islander people should
decide..
‘Men wouldn’t be asked if sexism was
eradicated, nor should women be asked
to fix sexism. Similarly white people
wouldn’t be asked if racism has been
eradicated and Indigenous people
shouldn’t be asked to fix it’
Dr Greg Phillips
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You’ve done well
for yourself
Aboriginal people
get so much given to
them
You’re too pretty
to be Aboriginal
“they’ve had
problems with my
sort of people”
You’re not a real
Aboriginal
Yes, but you’re
not like the rest
of them, you’re
different
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In straightforward terms…
Cultural racism positions
Aboriginal and Torres Strait
Islander peoples as ‘the
problem’.
Institutional racism occurs
when non-Aboriginal people
believe they have the
answers to address ‘the
problem’.
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Have teachers and
educators also done this
work about their
profession’s roles in
harmful practices?
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Reflective questions to address about cultural
safety
1. Have I really attended cultural safety training?
2. Are my colleagues and leaders attending cultural safety training?
3. What responsibility are Indigenous people taking to create cultural
safety in my profession and work context?
4. What leadership is taken in my profession and organisation to be
explicit about cultural safety in policy and practice? Who takes it?
What part do I play?
5. What organisational cultural change strategies are being
implemented?
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Signposts for cultural safety
ANMAC
Regulating systemic
and provider risk
2018 Code of
Conduct: Individual
professional level
2nd edition 2018:
Organisational
level
2018 Registered Nurse
Standards
2014 Midwife
Standards
2017 Enrolled Nurse
Standards
2018 Cultural
Safety Statement
of intent
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AHPRA Statement
The Statement of Intent has the vision that patient safety
for Aboriginal and Torres Strait Islander Peoples is the
norm and recognises that:
patient safety includes the inextricably linked elements of
clinical and cultural safety, and this link must be defined by
Aboriginal and Torres Strait Islander Peoples.
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National Safety and Quality
Health Service Standards
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What is the potential for cultural safety
to become part of accreditation
standards for wider learning institutions
– ie universities and schools, within
workforce education competency
standards, and codes of conduct – and
for your leadership to undertake cultural
safety and champion it?
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What are the similar processes for Indigenous
education, with the aim of growing the
workforce?
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Insights from the former Harvard
academic, William Ryan
Ryan wrote the following in relation to education
“…the middle class child is somewhat better prepared for
navigating the school experience than is the lower class child. But
would it not be reasonable to present this proposition in its reversed
form.
The education system is better prepared for the middle class child
than for the lower class child. Indeed, we could be tempted to say
further that the education experience is tailored for, and stacked in
favor of, the middle class child ”.
William Ryan, Blaming the Victim, Vintage Books, New York 1971
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Cultural determinants of health
Cultural They build:
stronger individual and collective identities
a sense of self-esteem
resilience
improved outcomes across the other
determinants of health, including:
education
economic stability
community safety
Brown, N 2014, Overview of cultural determinants,
The Lowitja Institute, Melbourne,
<http://www.lowitja.org.au/sites/default/files/docs/N
gaire-Brown.pdf>.
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Cultural determinants of health:
stronger individual and collective identities
self-determination
freedom from discrimination
individual and collective rights
freedom from assimilation and destruction
of culture
protection from removal/relocation
connection to, custodianship, and
utilisation of country and traditional lands
reclamation, revitalisation, preservation
and promotion of language and cultural
practices
protection and promotion of Traditional
Knowledge and Indigenous intellectual
property
understanding of lore, law and traditional
roles and responsibilities
Brown, N 2014, Overview of cultural determinants,
The Lowitja Institute, Melbourne,
<http://www.lowitja.org.au/sites/default/files/docs/N
gaire-Brown.pdf>.
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“The cultural determinants of health originate from and
promote a strength based perspective, acknowledging that
stronger connections to culture and country build stronger
individual and collective identities, a sense of self-esteem,
resilience, and improved outcomes across the other
determinants of health including education, economic
stability and community safety.”
Prof Ngaire Brown presentation at Exploring Cultural Determinants of
Health and Wellbeing Lowitja Institute Roundtable November 2014
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“Change will not come if we
wait for some other person, or
if we wait for some other time.
We are the ones we’ve been
waiting for.
We are the change that we
seek”
Barack Obama, presidential candidate
speech, June 4, 2005, Chicago
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Identifying dimensions of racism
Individual : Racial prejudice: Attitudes expressed towards those classified
on the basis of physical or cultural characteristics. People are identified as
members of a group and then judged according to presumed
characteristics.
Individual : Racial discrimination: Behaviour that disadvantages people
identified on the basis of their real or assumed membership of a ‘racial’ or
ethnic group.
System :Cultural racism: Racism expressed as a set of ideas based on social
myths about other ‘racial’ or ethnic groups. It devalues a group of people
by blaming that group for perceived differences.
System : Institutional Racism: Patterns of advantage and disadvantage are
sustained through structures such as laws, policies and practices that
exclude or discriminate against one group over another.
Adapted from: Pettman, J. & Chambers, B. (1996). Anti-racism: A handbook for educators. Canberra: AGPS; Vasta, E. & Castles, S. (Eds.) (1998). The
teeth are smiling. The persistence of racism in multicultural Australia. St Leonards, NSW: Allen & Unwin.
Editor's Notes
change MAP to show your country
This has nothing to do with what you are saying in the speech <3
In 2037, I know that when non-Indigenous people see me in the street or at work, their first reaction will not be of prejudice or fear, but of gratitude and pride.
This reflects their understanding of the profound value that indigenous peoples and cultures bring to Australian society.
In 2037, when my grandchildren get sick or need to go to the hospital, I no longer worry about whether their care will be respectful,
No longer do my people leave seeing a doctor or visiting a hospital to the last possible moment because of the fear of being humiliated or traumatised.
And I must say that in 2037 the transfer to the new Royal Adelaide hospital seems like decades ago!
Health conditions: Recent data on the prevalence and incidence of specific health conditions for Aboriginal and Torres Strait Islander Australians compared with non-Indigenous Australians shows continued marked discrepancies in terms of both morbidity and mortality, with burden of disease rates being substantially higher for Aboriginal and Torres Strait Islander Australians compared to all Australians. Here are a few examples:
Click The burden of disease for chronic respiratory diseases is 2.5 times higher.
Click The mortality rates for circulatory disease are 1.5 times higher.
Click Hypertension is 1.2 times more likely to occur with rates rising more sharply at a younger age.
There is a higher incidence of fatal, screen-detectable and preventable cancers, which are diagnosed at more advanced stages and often with more complex comorbidities.
Click The rate of diabetes amongst adults is over three times higher.
Click The rate of Stage 1 kidney disease is also over three times higher but Click increases to five times higher at Stage 4-5.
There is an earlier onset and persistence of otitis media; while it occurs more frequently it can also go undiagnosed, which can occur for non-Indigenous children, but is more likely to result in hearing loss.
As you can imagine, this has a direct impact on quality of life.
Section 4: Racism and cultural safety – courageous conversations - Racism in the lives of Aboriginal and Torres Strait Islander Australians
Exercise 2: Use material on slide. Take suggestions from the group about the percentage amount for the last two questions in callouts. Do each question one at a time – CLICK for each to come in.
Share the points on the slide of recent research – emphasise that the 2011 survey seems to reflect the more likely situation.
References
Ferdinand, A, Paradies, Y & Kelaher, M, 2013, Mental health impacts of racial discrimination in Victorian Aboriginal communities: the Localities Embracing and Accepting Diversity (LEAD) experiences of racism survey, The Lowitja Institute, Melbourne.
Gallaher, G, Ziercsh, A, Baum, F, Bentley, M, Palmer, C, Edmondson, W & Winslow, L, 2009, In our own backyard: urban health inequities and Aboriginal experience of neighbourhood life, social capital and racism, Flinders University of SA, Adelaide.
Miller, S, Gibson, S, Sudano, L & Edwards, S, 2009, Ever felt like complaining? Final report, Health and Community Services Complaints Commission, Adelaide, <http://www.hcscc.sa.gov.au/documents// 02_what's%20new/h_EverFeltLikeComplainingReportFINALWeb.pdf>.
Paradies, Y, Harris, R, Anderson, I, 2008, The impact of racism on Indigenous health in Australia and Aotearoa: Towards a research agenda, Cooperative Research Centre for Aboriginal Health and Flinders University, Casuarina, NT
Kathleen to present
All of these reports draw on research that has adjusted for other factors that could influence outcomes, such as age, gender, socioeconomic status, location, health service characteristics, co-morbidities etc.
References
Larson, A, Gilles, M, Howard, P & Coffin, J, 2007, It's enough to make you sick: the impact of racism on the health of Aboriginal Australians, Australian and New Zealand Journal of Public Health, 31;4, 322–9
Paradies, Y, Trenerry, B, Franklin, H & Guerin, P, 2010, Towards culturally competent organisations. Presentation to the Executive of SA Health, Adelaide, May 2010.
Poche Networks for Indigenous Health, 2014, Health services, racism and Indigenous health: gaining traction for systemic change, Flinders University, Adelaide.
Section 2: Health workforce, health inequities and the relevance of cultural safety – The Aboriginal and/or Torres Strait Islander nursing and midwifery workforce
An important strategy for creating health equity for Aboriginal and/or Torres Strait Islander Australians is building the Aboriginal and Torres Strait Islander health workforce.
Many Aboriginal and/or Torres Strait Islander students enrol in nursing and midwifery but do not graduate.
We know that in the university sector only 34% of our students who start studying nursing end up graduating. Some of the factors are listed on the right side of the graph.
While we have not been able to access more recent figures from the Australian Government on university completion rates, anecdotally through Members and universities, we are aware that the gap in completion rates is still wide.
We are going to start by reflecting on our own experiences to date, and our understanding and abilities, because a core requirement for developing a good understanding of cultural safety is candid self-reflection, so let’s do a quick self-reflective exercise.
Do each question one at a time – CLICK to bring each one in. Question 2 is simply a Yes/No response. For questions 1, 3 and 4, use post-it notes of the same colour as the 5-point scale for each question. Each participant will write the number that fits with their rating on the relevant colour post-it. Ask people to stick them on the wall/floor/a spare table (depending on available space) so the overall picture can be seen without specific people being identified. Alternatively, ask people to physically stand up to represent the rating scale across the room, i.e. a values walk.
Here are some notes on how you may do this:
Question 1: Assess your understanding of cultural safety. Choose a position on this 1 to 5 rating scale – half way positions are fine.
Question 2: There have been options to attend cultural training for some time – although different words have been used between the words ‘cultural’ and ‘training’. You may have attended such training on one or more occasions. Based on your current interpretation of cultural safety training, who would say they have attended it?
Question 3: Now assess your ability to explain to someone else the difference between cultural awareness and cultural safety training?
Question 4: Finally, assess your ability to teach cultural safety to nursing and/or midwifery students?
People often approach cultural awareness training as an opportunity to gain a tick-list on how to work with Aboriginal and/or Torres Strait Islander people.
Due to the huge diversity of Aboriginal and/or Torres Strait Islander nations, there is no cookie cutter approach to doing this.
Here are a starting set of questions at a professional but also at an organisational level.
The first two relate to the exercise earlier today on the distinctions between cultural safety and cultural awareness training.
The next three focus on responsibility from leaders and peers in supporting professional and organisational cultural change for cultural safety.
In the next exercise you will look at these in a deeper manner.
To tackle these big issues WE face ?
Here are some suggestions:
Embed cultural safety in your organisation’s strategic plan, and Reconciliation Action Plan.
Make anti-racism practice part of your everyday -- whether you are at home or at work -- and whether anyone is looking or not. Enact zero tolerance for racism.
Ensure your governance structures reflect the communities who you are serving.
Privilege the voices and the wisdom of Aboriginal and Torres Strait Islander people and organisations.
Inform yourself about 18C and Constitutional Recognition
Inform yourself about climate change and the actions you can take -- and try to put aside non-Indigenous lenses when doing this. Learn from us about caring for country.
Advocate for a National Truth and Reconciliation Commission
Practise trust, respect and reciprocity. Build and value your relationships with us.
Janine to present
So, let’s come back to our sector. Former Harvard academic, William Ryan, offers some direction for us:
Ryan wrote the following in relation to education, but it can be transferred into the health context by replacing the word “school” with “health system” and “child” with “consumer”.
Read this: “…the middle class [consumer] is somewhat better prepared for navigating the [health system] experience than is the lower class [consumer]. But would it not be reasonable to present this proposition in its reversed form.
The [health system] is better prepared for the middle class [consumer] than for the lower class [consumer]. Indeed, we could be tempted to say further that the [health system] experience is tailored for, and stacked in favor of, the middle class [consumer]”.
Unequivocally, this is describing institutional racism. We must become far more observant of and articulate about the pervasive presence of institutional racism – this is directly addressed in cultural safety training.
The cultural determinants of health originate from and promote a strengths-based perspective, acknowledging that stronger connections to culture and country build Click:
stronger individual and collective identities
a sense of self-esteem
resilience
improved outcomes across the other determinants of health, including: education, economic stability and community safety (Brown, 2014).
The cultural determinants of health are consistent with the thematic approach to the Articles of the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) (<http://www.un.org/esa/socdev/unpfii/documents/DRIPS_en.pdf>). They include, but are not limited to:
• self-determination
• freedom from discrimination
• individual and collective rights
• freedom from assimilation and destruction of culture
• protection from removal/relocation
• Click connection to, custodianship, and utilisation of country and traditional lands
• reclamation, revitalisation, preservation and promotion of language and cultural practices
• protection and promotion of Traditional Knowledge and Indigenous intellectual property
• understanding of lore, law and traditional roles and responsibilities (Brown, 2014).
OPTIONAL: Only use if facilitators agree and there is time.
Janine Mohamed’s reframing of this image and commentary.
I now want to step into some concepts that CATSINaM works with and has defined – the first one is racism
A topic that needs to be understood and talked about if we want to close the GAP and is now mentioned in the NATSIHIP
We could spend hrs exploring these concepts in detail but this is breief overview
The first two dimensions are individual responses where we have a choice to act upon them:
Racial prejudice: its an Attitude - it can expressed in your head or said out load:
Your too pretty to be Aboriginal ,or you don’t look Aboriginal, comments like ‘yes but your not like the rest of them your different’
Seeing Aboriginal people and feeling unsafe, or feeling like you can’t ask someone if they are Aboriginal? HP report that they feel uncomfortable
Acting on this racial discrimination – the behavior
Examples include – Security following people, refused entry, emergency departments – being triaged into a down graded care pathway compared to non indigenous people with the same symptoms, (evidence based research that supports this phenomenon )
Racial Prejudice and Discrimination is fed by :
Cultural racism------ – it’s sown into us unconiously, and it’s out of our individual control: The problem is placed with Aboriginal people
For example the language used i.e. the Aboriginal health problem
An alternative to this is this is “these are the issues Aboriginal people face”
Aboriginal people get a lot of benefits
Aboriginal people drink a lot
Without exploring where these beliefs come from
Institutional Racism: again out of our individual control – Exclusions in Governance structures, sporting codes where we are over-represneted and yet there are no Indigenous coaches CEO or president at these clubs
We can
