Culturally safe care for Aboriginal and Torres Strait Islander peoples

Case scenario

Sandra is the pharmacist in charge at a community pharmacy in a large regional town. After conducting a MedsCheck for a local Aboriginal man, she started to think about the services the pharmacy provides to the local Aboriginal community. Sandra wanted to ensure that Aboriginal and Torres Strait Islander peoples felt safe and comfortable attending the pharmacy, and that the services provided were in the best interests of patients. She contacted the local Aboriginal Health Service which arranged for an Aboriginal and Torres Strait Islander health practitioner as well as a local Elder to meet with her and other senior pharmacists to discuss cultural safety in the pharmacy.

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Introduction

Australia has the oldest continuing living culture in the world.¹ Aboriginal and Torres Strait Islander cultures are diverse and rich, and made up of hundreds of different groups.² Each group has its own culture, customs, language and laws.^1,3,4 In 2021, 3.8% of the Australian population identified as being Aboriginal or Torres Strait Islander.⁵ More than one-third of Aboriginal and Torres Strait Islander peoples live in major cities (38%), with 44% living in inner and outer regional areas and 17% living in remote and very remote areas.²

Pharmacists working in all parts of Australia and in all practice areas will provide care to Aboriginal and Torres Strait Islander peoples. The Professional Practice Standards outlines the practice expectations of all Australian pharmacists. It highlights the obligations of pharmacists to practise in a way that is culturally safe, including the importance of regularly reviewing themselves, co-workers and the workplace for cultural responsiveness.⁶ Similarly, the Code of Ethics for Pharmacists identifies the ethical need for pharmacists to provide culturally safe and responsive care.⁷ The PSA has released Guidelines for Pharmacists Supporting Aboriginal and Torres Strait Islander Peoples with Medicines Management⁸ to support pharmacists in providing culturally safe care to Aboriginal and Torres Strait Islander peoples, regardless of practice setting. Additionally, in October 2022, the Health Practitioner Regulation National Law was updated to recognise cultural safety as a guiding principle and objective.⁹ This ensures a shared commitment by all parts of the National Scheme (practitioners, regulators, accreditation authorities, educators and employers) to provide healthcare services that are culturally safe.^9,10

What is culturally safe care? 

A health system that is culturally safe respects the cultural values, strengths and differences of Aboriginal and Torres Strait Islander peoples, respects their rights and addresses racism and inequity.^11-13 Both health professionals and health services need to be culturally responsive, and be actively involved in addressing racism and power imbalances that may be present. It also requires active involvement of Aboriginal and Torres Strait Islander patients to ensure the health service is meeting their requirements.¹⁴ Cultural safety is defined by the experience of Aboriginal and Torres Strait Islander peoples who attend and use the health service, and includes both the treatment they receive from health professionals and the extent to which they feel culturally safe.¹⁴

Other related terms include ‘cultural awareness’, ‘cultural competency’ and ‘cultural respect’. Together, these all contribute to providing culturally safe care.^8,12

• Cultural awareness is a basic understanding of a wide range of cultures found in the population. There is an awareness of the similarities and differences between cultures, and this knowledge is applied to optimise communication with those from another culture.^12,15
• Cultural competency is an extension of cultural awareness. It is greater than individual skills or knowledge but also includes appreciating and understanding cultural differences and being accepting of these. Cultural competency also involves not seeing one’s own behaviours, beliefs and actions as the norm.^12,15 Personal cultural competence involves the actions a person takes individually to increase their knowledge of other cultures and then using that to adapt the services provided.¹⁵ Cultural competency at a health service level is an extension of individual skills and knowledge and influences the way a health service provides care to people of different cultures.¹²
• Cultural respect occurs when individual people feel safe and there is respect for cultural differences.¹² It also includes recognising, protecting and advancing the rights, cultures and traditions of a specific culture.¹⁵

Cultural safety and responsiveness require a commitment to ongoing learning and self-reflection.^8,12 A single education session will not create a workplace that is culturally competent, however it may increase the cultural awareness of staff.¹²

Features of cultural safety

Essential components of a culturally safe environment include¹²:

• understanding one’s own culture
• acknowledging the differences between cultures, and the need for staff to be actively aware of and respectful of these differences
• knowing the theory of power relations
• appreciating the historical context of colonisation, racist practices that have occurred at individual and institutional levels, and the impact these have had on Aboriginal and Torres Strait Islander peoples’ lives and wellbeing, both in the past and the present
• understanding that the presence or absence of cultural safety is determined by the person receiving care, and not defined by the health service or health worker.

The importance of providing culturally safe care

Providing culturally safe and effective care is essential for optimising access to healthcare services as well as health outcomes for individuals.⁷ When Aboriginal and Torres Strait Islander peoples are treated in a way that is unfair or unequal because of their race, culture or language, they can be less likely to access healthcare, or, if they do receive care, are less likely to feel comfortable or culturally safe.¹⁴

In 2020, it was found that more than one in five (22%) of Aboriginal and Torres Strait Islander peoples or their families experienced racial discrimination by doctors, nurses and/or medical staff in the previous 12 months.¹⁴ Lack of a culturally safe environment is a common reason for Aboriginal and Torres Strait Islander peoples to leave hospital before commencing or completing treatment.¹⁴

The benefits of improving cultural safety are outlined in Table 1.

General strategies for providing culturally safe care

The Australian Health Practitioner Regulation Agency (Ahpra) provides the following advice for health practitioners, including pharmacists, to practise in a way that is culturally safe, responsive and respectful¹⁶:

• Acknowledge colonisation and systemic racism, and social, cultural behavioural and economic aspects that affect the health of both the individual and community.
• Acknowledge and address individual racism, and one’s own biases, assumptions, stereotypes and prejudices, and provide healthcare services that are holistic and are without biases and racism.
• Identify the importance of self-determined decision-making, partnership and collaboration in healthcare that is driven by the individual, family and community.
• Develop a working environment that is safe through leadership that supports the rights and dignity of Aboriginal and Torres Strait Islander peoples and colleagues.

Respect

When Aboriginal and Torres Strait Islander peoples are treated with respect, understanding and empathy by health professionals they are more likely to feel culturally safe. Treating people with respect also supports increased trust and confidence in the care they receive.¹⁴ Pharmacists should avoid being judgmental or making assumptions. Attitudes that are judgmental or racist are barriers to forming relationships and are not always recognised. Regularly undertaking self-reflection can assist with recognising and monitoring any personal cultural bias.⁸

Communication

Communication is an important component to assist patients in feeling culturally safe. This includes showing an awareness and interest in Aboriginal and Torres Strait Islander cultures. Communication that is respectful also improves the likelihood that Aboriginal and Torres Strait Islander peoples will access healthcare and that they will receive more effective care.¹⁷

Learning about patients’ cultural views in terms of their health and healthcare is also important for optimising the healthcare services provided and outcomes, including their¹⁷:

• concept of health
• health beliefs around wellness and causes of injuries or sickness, treatment of medical conditions (including bush medicines and traditional healers), beliefs about food and diet (including taboos), structure of family/kinship and different roles and responsibilities, and death and dying (if relevant and appropriate)
• protocols and practices that are cultural and gender-specific.

Empowerment

People feel empowered when they are included in decisions about their healthcare, receive information about their rights as healthcare consumers, and when they have some control over the care they receive.¹⁴

Involvement of family

Involving family members, or other people important to the patient, in the healthcare provided and the decisions made about their healthcare, with the patient’s consent, can help Aboriginal and Torres Strait Islander peoples feel more culturally safe. It can also enhance the quality and effectiveness of the care provided.¹⁴

Ongoing self-reflection and quality improvement

Ongoing quality improvement is required to establish and maintain a culturally safe health service.¹² Pharmacists should identify their own learning requirements (and those of their staff) so that they provide care that is culturally safe and responsive and free from racism. Ongoing self-reflection of one’s knowledge, skills, attitudes, practice behaviours and power differences is important.⁸ Pharmacists and their staff should reflect on their own culture and consider how their behaviours are impacted by this and the culture that is dominant in the healthcare system.⁸ Any learning needs identified should be included in a pharmacist’s individual continuing professional development (CPD) plan.⁸

Leadership

Pharmacists can take on a leadership role in supporting cultural safety and preventing racism in their workplace by ensuring⁸:

• the service/organisation is culturally responsive and systems have been adopted to ensure there is no organisational racism
• the induction process for new staff includes details and context about the local community
• systems for reporting racism are in place, including appropriate follow-up, and managers have adequate skills to handle complaints involving racism.

Table 1 – Benefits of cultural safety in healthcare

Strategies to ensure care is culturally safe 

To provide a health service that is culturally safe, it is essential to engage with the local community when designing and delivering services.⁸ As there is a diversity of cultures across Australia that are all unique, it is important for pharmacists to learn about, engage with and invest in the local culture in which they live and work.⁸

Pharmacists should look to establish relationships with cultural training providers both individually and organisationally.⁸

Working with the local Aboriginal Health Service, Aboriginal and Torres Strait Islander health workers/health practitioners and Indigenous liaison officers can assist with gathering community-specific advice to help the healthcare environment be culturally safe. Local Elders and Aboriginal and Torres Strait Islander peoples can also be asked.⁸

Aboriginal and Torres Strait Islander peoples and services are using their intellectual property when providing advice, and it should be expected that there is reciprocity or they are paid for the cultural expertise they provide.

More information about co-design and co-development of services, programs and strategies can be found in the PSA Guidelines.⁸

Actions that can be taken to provide a culturally safe environment include^8,12,18:

• displaying local artwork and flags
• displaying a sign that acknowledges the traditional custodians of the land the workplace is on
• celebrating and proactively participating in events (both in the workplace and community) that are important to the Aboriginal and Torres Strait Islander cultures
• providing culturally appropriate resources (e.g. brochures, posters)
• employing, mentoring or building relationships with Aboriginal and Torres Strait Islander health workers, and respecting their clinical and cultural skills, contributions and knowledge
• improving employment of Aboriginal and Torres Strait Islander peoples across the health workforce and supporting them to reach their potential.

Workplace policies, procedures and systems should be reviewed regularly to ensure they support the provision of care that is culturally safe, and be updated when needed.⁸ Developing and discussing a reconciliation action plan and position statement that covers cultural responsiveness and a commitment to action is also important.⁸ There should be regular training provided on cultural awareness and safety, and this should also be a part of performance management reviews.⁸

Knowledge to practice 

Providing culturally safe care to Aboriginal and Torres Strait Islander peoples is important and relevant to pharmacists working in all practice areas. Pharmacists should regularly self-reflect on their practices and beliefs, and identify and address any gaps so as to improve their practice so that it is culturally safe. This can be included in their CPD plan. Pharmacists should also regularly review the practices in their workplace and those of their staff, provide education and support, and make changes where necessary to make their health service more culturally safe. Pharmacists can use the PSA Guidelines⁸ for guidance on improving services for Aboriginal and Torres Strait Islander peoples.

Conclusion

Providing culturally safe healthcare is essential for improving and optimising health outcomes and services provided to Aboriginal and Torres Strait Islander peoples, and is relevant to all health settings. Providing culturally safe healthcare is an ongoing process, and authentic community engagement with members of the local Aboriginal and Torres Strait Islander communities (e.g. local Elders) for advice on how to make the service culturally safe is important. The PSA Guidelines⁸ provide further information for pharmacists on how to provide culturally safe care, and also includes information on further resources to support pharmacists.

Key points

• Cultural safety is important for achieving the best health outcomes for patients.
• The presence or absence of cultural safety is defined by the individual that is receiving care, and is not defined by the health service or health professional.
• Cultural safety requires a commitment to ongoing learning and self-reflection.
• Establishing a culturally safe environment requires engaging with the local community when designing and delivering services.

If you do get an enrolment error, please click here

References

1. Australian Human Rights Commission. Aboriginal and Torres Strait Islanders: Australia’s first peoples. At: humanrights.gov.au/our-work/education/aboriginal-and-torres-strait-islanders-australias-first-peoples 
2. Australian Government Australian Institute of Health and Welfare. Profile of Indigenous Australians. 2022. At: www.aihw.gov.au/reports/australias-health/profile-of-indigenous-australians 
3. The Australian Institute of Aboriginal and Torres Strait Islander Studies. Indigenous Australians: Aboriginal and Torres Strait Islander people. 2020. At: https://aiatsis.gov.au/explore/indigenous-australians-aboriginal-and-torres-strait-islander-people 
4. The Australian Institute of Aboriginal and Torres Strait Islander Studies. Map of Indigenous Australia. 2022. At: https://aiatsis.gov.au/explore/map-indigenous-australia 
5. Australian Bureau of Statistics. Estimates of Aboriginal and Torres Strait Islander Australians. 2021. At: www.abs.gov.au/statistics/people/aboriginal-and-torres-strait-islander-peoples/estimates-aboriginal-and-torres-strait-islander-australians/jun-2021 
6. Pharmaceutical Society of Australia. Professional practice standards. Version 6. Canberra: PSA; 2023.
7. Pharmaceutical Society of Australia. Code of Ethics for Pharmacists. Canberra: PSA; 2017.
8. Pharmaceutical Society of Australia. Guidelines for pharmacists supporting Aboriginal and Torres Strait Islander peoples with medicines management. Canberra: PSA; 2022.
9. Australian Health Practitioner Regulation Agency. Joint statement: Aboriginal and Torres Strait Islander health and cultural safety at heart of National Law changes. 2022. At: www.ahpra.gov.au/About-Ahpra/Ministerial-Directives-and-Communiques/National-Law-amendments/Joint-statement.aspx
10. Australian Health Practitioner Regulation Agency. Legislation. At: www.ahpra.gov.au/about-ahpra/what-we-do/legislation.aspx
11. Australian Government Australian Institute of Health and Welfare. Indigenous Australians and the health system. 2022. At: www.aihw.gov.au/reports/australias-health/indigenous-australians-use-of-health-services
12. The Wardliparingga Aboriginal Research Unit of the South Australian Health and Medical Research Institute. National Safety and Quality Health Service Standards: User guide for Aboriginal and Torres Strait Islander health. Sydney: Australian Commission on Safety and Quality in Health Care; 2017.  
13. Australian Human Rights Commission. UN Declaration on the Rights of Indigenous Peoples. 2007. At: https://humanrights.gov.au/our-work/un-declaration-rights-indigenous-peoples-1
14. Australian Government Australian Institute of Health and Welfare. Cultural safety in health care for Indigenous Australians: monitoring framework. 2022. At: www.aihw.gov.au/reports/indigenous-australians/cultural-safety-health-care-framework/contents/module-2-patient-experience-of-health-care
15. Health Education and Training. Cultural awareness. 2022. At: www.heti.nsw.gov.au/education-and-training/courses-and-programs/international-medical-graduate-information/cultural-awareness
16. Australian Health Practitioner Regulation Agency. Code of conduct. 2022. At: www.ahpra.gov.au/Resources/Code-of-conduct/Shared-Code-of-conduct.aspx
17. Queensland Health. Aboriginal and Torres Strait Islander patient care guideline. Brisbane: Queensland Health; 2014.
18. Australian Government Australian Institute of Health and Welfare. Cultural safety in health care for Indigenous Australians: monitoring framework. 2019. At: https://www.aihw.gov.au/reports/indigenous-australians/cultural-safety-health-care-framework/contents/about

Our authors

Naomi Weier (she/her) BPharm(Hons), GradCertPharmPract, GradDipClinEd, MClinPharm, CertIV TAE, AACPA, AICGG, MPS is an accredited pharmacist and PhD candidate. She has experience working in various pharmacy sectors including Aboriginal and Torres Strait Islander health, and community and hospital pharmacy.

Our reviewer

Chastina Heck (she/her) BPharm, PostGradDipClinPharm is a Nywaigi woman living on Yolngu country and Pharmacy Manager at Gove District Hosptial, NT.