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Cultural Sensitivity

Working effectively with culturally diverse clients and co-workers

Objectives

• Understand the concepts of culture, cultural safety and cultural competence

• Accept cultural diversity as a basis for effective workplace and professional relationships

• Motivate health workers to critically reflect on their own and others' attitudes towards

racial and ethnic differences, supporting them to acquire generic skills that will improve

their ability to work in a more culturally sensitive way

• Identify resources and strategies to provide culturally appropriate health services to

Aboriginal and Torres Strait Islander people

• Outline the principles of cultural competence in an Australian maternity care setting


Contents

Working effectively with culturally diverse clients and co-workers ...................................................... 1

Objectives ................................................................................................................................................... 1

What is culture? .......................................................................................................................................... 3

Relevant terms and definitions ................................................................................................................. 3

How does your culture shape how you see the world, interact with others and approach your work? ........................................................................................................................................................... 6

Iceberg concept ........................................................................................................................................ 9

Why is awareness of CULTURE important for health care providers? ................................................. 10

Types of culture ......................................................................................................................................... 11

Working effectively with Aboriginal and Torres Strait Islander people ............................................... 13

Cultural considerations in maternity care ............................................................................................. 18

Summary .................................................................................................................................................... 21

References: ............................................................................................................................................... 22

Underpinning this cultural sensitivity/cultural safety resource is the concept that if health professionals know more, they will be more tolerant of other cultures and make considered adjustments to their behaviour at work, enhancing the relationship for both the client and the health worker.

The aim is to sensitise health care providers to factors, which universally affect cultural behaviours, not just focus on aspects relevant only to specific cultural or ethnic groups.

Developing cultural competence is a lifelong process, not solely achieved by reading or attending a single cultural orientation presentation. Seeking professional development strategies which will increase your understanding of cultural difference and diversity can help you to provide culturally secure health care.

By increasing cultural awareness in staff, health service providers can respond more appropriately to the needs of people from diverse communities and their carers recognise the role of traditional health beliefs and practices and appreciate the significance of informal support networks.

The information provided in this resource is relevant to all cross cultural encounters and highlights factors specific to working with Australian Aboriginal and Torres Strait Islander people. The format is designed to be a gateway or resource for cultural safety awareness. It does not seek to be a training program. Health professionals are strongly encouraged to seek opportunities to attend cultural safety / cultural competency training in their own workplaces. Suggestions for further learning are included throughout the document.


What is culture?

Our culture reflects our values. Our culture is who we are; our traditions and the basis of our attitudes and patterns of behaviour. It is not only related to race or ethnicity, but includes gender, social class, sexual orientation, age, religious or spiritual belief, occupational group, generation or a combination of any or all variables. When we refer to our “culture” we mean a group with a shared system of values, beliefs, history, and learned patterns of behavior that the group uses to generate meaning among its members and influence decision-making. It is a dynamic concept, which is influenced by environmental, historical, political, geographical, linguistic, spiritual and social factors. Culture reflects traditions passed down through generations but is active and changes over time. People can belong to many different subcultures.

Cultural values refer to the individual's desirable or preferred way of acting or knowing something, that is sustained over a period of time and which governs their actions or decisions.

Cultural diversity may include:

• Ethnicity • Race • Language • Cultural norms and values • Religion • Beliefs and customs • Kinship and family structures and relationships • Personal history and experience, which may have been traumatic • Gender and gender relationships • Age • Disability • Sexuality • Special needs

Relevant terms and definitions

Cultural awareness:

“Cultural awareness is the foundation of communication and it involves the ability of standing back from ourselves and becoming aware of our cultural values, beliefs and perceptions. Why do we do things in that way? How do we see the world? Why do we react in that particular way? Cultural awareness becomes central when we have to interact with people from other cultures. People see, interpret and evaluate things in a different ways. What is considered an appropriate behaviour in one culture is frequently inappropriate in another one. Misunderstandings arise when I use my meanings to make


sense of your reality. Increasing cultural awareness means to see both the positive and negative aspects of cultural differences.” 1

Cultural sensitivity: extends beyond awareness and encourages self-reflection on personal attitudes and experiences of the individual health professional and how this may impact on the way they communicate and behave with people outside of the dominant culture.2

Cultural safety: Irihapeti Ramsden, a Maori nurse and activist initiated the idea of cultural safety for nurses. She explained it thus; “…cultural safety places an obligation on the nurse or midwife to provide care within the framework of recognizing and respecting the difference of an individual. But it is not the nurse or midwife who determines the issue of safety. It is the consumers or patients who decide if they feel safe with the care that has been given.”3

In Australia, cultural respect/safety has been defined and promoted through the ‘Cultural Respect Framework for Aboriginal and Torres Strait Islander Health: 2004-2009’4 that was released in 2004 by the Australian Health Minister’s Advisory Council’s Standing Committee on Aboriginal and Torres Strait Islander Health. The Framework explained that cultural respect occurs when the “health system is a safe environment” for Aboriginal Peoples and where cultural differences are respected. Further, that respect includes the right to achieve “equitable health outcomes”.

1 Quappe, S., Cantatore, G. 2005. ‘What is Cultural Awareness, anyway? How do I build it?’ Viewed August 18th 2014 http://www.culturosity.com/articles/whatisculturalawareness.htm 2 National Aboriginal Community Controlled Health Organisation. May 2011. ‘NACCHO Cultural Safety Training Standards: A background paper’, p.10. Viewed 19th August 2014. http://www.naccho.org.au/download/cultural_safety/CSTStandardsBackgroundPaper.pdf

3 Nursing Council of New Zealand. (March 2002). ‘Guidelines for Cultural Safety, the Treaty of Waitangi, and Maori Health in Nursing and Midwifery Education and Practice’. Viewed 19th August 2014. http://nursingcouncil.org.nz/About-us/Treaty-of-Waitangi

4 Australian Health Ministers’ Advisory Council - Standing Committee on Aboriginal and Torres Strait Islander Health Working Party, AHMAC Cultural Respect Framework for Aboriginal and Torres Strait Islander Health, 2004 – 2009, AHMAC 2004. Viewed 19th August 2014 http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-oatsih-pubs-crf.htm;


For an awareness of cultural safety from an Aboriginal and Torres Strait Islander perspective view the complete video

(http://youtu.be/PfrIW9EUi4g?t=2s)

Key Points from this video (Awareness of Cultural Safety) Issues

• Culturally appropriate consultation process • Miscommunication and misunderstandings • Language and body language

Kerry Taylor - Senior Lecturer, Poche Centre

• "Trust and relationships are paramount with Aboriginal people... particularly in this setting where relationships are part of health"

• Having strong positive relationships equals health • "... when dealing with a particular health issue, the

relationship is part of the management" Dianne Stephens - Darwin Hospital

• It is different for different communities • There is not just one community and one culture

Ricky Mengatha - Clinical Research, Baker IDI

• Central Australia language complexities • People take away mixed messages and not apply them

based on the directions given by the physician • Building relationship • Removing distrust

Cultural competence: cultural competence is more than awareness of cultural differences, as it focuses on the capacity of the health system to improve health and well-being by integrating culture into the delivery of health services5. It is a process that requires humility as practitioners continually self-reflect and self-critique in an effort to develop and maintain mutually respectful and dynamic partnerships with communities on behalf of individual patients. Cultural competency in the context of health care provision consists of:

• Awareness and acceptance of cultural differences • Awareness of one’s own cultural values • Recognition that people of different cultures have different ways of communicating,

behaving, interpreting, and problem-solving • Recognition that cultural beliefs impact patient’s health beliefs, help-seeking

activities, interactions with health care professionals, health care practices, and health care outcomes, including adherence to prescribed regimens.

• An ability and willingness to adapt the way one works to fit the patient’s cultural or ethnic background in order to provide optimal care for the patient.

5 National Health and Medical Research Council 2006, Cultural Competency in Health: A Guide for policy, partnerships and participation, Commonwealth of Australia, Canberra. Viewed 18th August 2014. http://www.lowitja.org.au/congress-2014/workshops/cultural-competency#sthash.D42S8wX.dpuf


REMEMBER:

We all have as much culture as one another! No-one is culturally neutral. We all have the right to value things differently.

Follow the link to watch an explanation of cultural diversity: http://youtu.be/ZDvLk7e2Irc

How does your culture shape how you see the world, interact with others and approach your work?

In a multicultural society such as Australia, health workers are likely to encounter clients from diverse settings. State health departments are recognising that this diversity needs to be acknowledged and guidelines developed to prepare a culturally safe environment for all staff and clients. For example:

• More than one third of Queenslanders was either born overseas or had a parent who was born overseas, and these people speak more than 270 different languages. Queensland Health recognises that in order to achieve its purpose of providing safe, sustainable, efficient, quality and responsive health services for all Queenslanders, it is important to ensure that the services it provides are culturally competent. To achieve organisational cultural competency, Queensland Health has developed an organisational cultural competency framework as part of the Queensland Health Strategic Plan for Multicultural Health 2007- 2012. 6

• NSW is recognised internationally as one of the most culturally and ethnically diverse states in the world. At the last Census, 1,623,600 people were born in a non-English speaking country and collectively they spoke over 150 different community languages. Diversity in culture, ethnicity and language is a hallmark of Australia's large cities and has increasingly become a feature of many smaller regional communities. A kaleidoscope of customs, languages, religions and social beliefs has added new energy, dynamism and cosmopolitan sophistication, to the State of NSW. The NSW Health Policy and Implementation Plan for Healthy Culturally Diverse Communities provides an opportunity for all levels of NSW Health system to revise strategies and

6 Queensland Government. ‘Queensland Health Strategic Plan for Multicultural Health 2007- 2012’. Viewed 18th August 2014. http://www.health.qld.gov.au/multicultural/contact_us/framework.asp


service models to better meet the contemporary needs of culturally and linguistically diverse clients in NSW. 7

• The Victorian Government’s Building on our strengths: a framework to reduce race-based discrimination and support diversity in Victoria has been developed recognising that there are benefits in addressing discrimination affecting both Indigenous and culturally and linguistically diverse (CALD) communities through a common planning framework, while recognising that there are both similarities and differences in the experiences of these two groups. 8

A person’s ethnic, religious and linguistic background creates a range of influences that have an ongoing impact on physical and mental health status throughout their life. These influences are particularly significant during settlement in a new country and especially for groups with high needs such as refugees. As health professionals we need to develop a cultural insight and a deeper appreciation and respect for the rights of culturally diverse individuals. When cultural beliefs and practices are not appropriately identified, the significance of behaviour may confuse health workers and result in the delivery of inappropriate care. Don’t make the mistake of confusing symbols with values; for example a woman wearing a hijab (headscarf) may express a variety of religious, cultural or political values. Don’t be tempted to rush to a conclusion that stereotypes her as ‘obviously Muslim’.

Ask questions if unsure; don’t make assumptions based on stereotyping.

We learn language and culture together and each reflects the other. Miscommunication is where all misunderstandings occur when working across cultures. Culture and language have significant impact on how patients access and respond to health care services. Many groups communicate and make decisions differently to westerners. Different cultures (and subcultures) may have different rules and norms. Understanding the other's culture facilitates cross-cultural communication.

In the literature culture has been compared to an iceberg, referring to the fact that so much goes undetected. When we see an iceberg, the portion which is visible above water is, in reality, only a small piece of a much larger whole. Similarly, people often think of culture as the observable characteristics of a group that we can ‘see’ with our eyes, be it their food, dances, music, arts, or greeting rituals.

Prejudices mostly start on this symbolic and observable level. We should never forget that, any opinion we voice regarding explicit culture usually says more about where we come from than the community we are judging.

7 NSW Government. ‘Policy and Implementation Plan for Healthy Culturally Diverse Communities 2012–2016’. Viewed 18th August, 2014. http://www.mhcs.health.nsw.gov.au/policiesandguidelines/pdf/policy-and-implementation-plan-for-healthyculturallydiverse2012-2016.pdf 8 Victorian Health Promotion Foundation (VicHealth). ‘Building on our strengths. A framework to reduce race-based discrimination and support diversity in Victoria. Summary report’. Viewed 19th August 2014. http://www.vichealth.vic.gov.au/~/media/ProgramsandProjects/Publications/Attachments/Building_on_our_strengths_Summary.ashx


Deep below the ‘water line’ are a culture's core values. These are primarily learned ideas of what is good, right, desirable, and acceptable, as well as what is bad, wrong, undesirable, and unacceptable. In many cases, different cultural groups share the similar core values (such as "honesty", or "respect", or "family"), but these are often interpreted differently in different situations and incorporated in unique ways into specific attitudes we apply in daily situations.

This concept is best illustrated in diagram below. 9

9 https://www.google.com/search?q=iceberg%20concept%20of%20culture&gws_rd=ssl&tbm=isch


Iceberg concept

Indiana Department of Education Office of English Language Learning & Migrant Education

Further reading (for interest only);

Deborah Dysart-Gale. (2006). Cultural Sensitivity Beyond Ethnicity: A Universal Precautions Model. The Internet Journal of Allied Health Sciences and Practice, 4(1).

Hanley, Jerome. Beyond the Tip of the Iceberg: Five Stages Towards Cultural Competence. Viewed 19th August 2014. https://www.google.com/search?q=iceberg%20concept%20of%20culture&gws_rd=ssl&tbm=isch

Queensland Health: http://www.health.qld.gov.au/multicultural/health_workers/for_hlth_workers.asp

Pappa, E. Ramsden, I. Cultural safety in nursing: the New Zealand experience. International Journal for Quality in Health Care, Vol 8, No 5 pp. 491-497. 1996

Department of Health and Ageing (2011) National Health Reform: improving primary health care for all Australians. (Australian Government: Canberra) Available at http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/content/nathealthref


Why is awareness of CULTURE important for health care providers?

When we talk about culturally diverse health care we refer to the variability of approaches needed to provide culturally appropriate care that incorporates an individual’s cultural values, beliefs, and practices including sensitivity to the environment from which the individual comes and to which the individual may ultimately return.10

Culture influences all health practices and beliefs. Culture is a key factor in determining status of health and notions of quality of life. Illness behaviour is determined by culture. Treatment of ill health is greatly determined by the cultural practices of service providers. Compliance with treatment is largely affected by cultural factors. In order to communicate effectively across cultures health professionals need to be sensitive and adaptive to varying cultural norms in relation to verbal and non-verbal communication.

Cultures are typically divided into two categories: collectivist and individualist. Individualist cultures, such as for example, “mainstream” Australia, emphasize personal achievement regardless of the expense of group goals, resulting in a strong sense of competition. Aboriginal and Torres Straight Islanders however embrace a collectivist culture. Collectivist cultures emphasize family and work group goals above individual needs or desires. The majority of the world (85%) belong to a collectivist culture, that is, one in which people tend to view themselves as members of groups (families, work units, tribes, nations), and usually consider the needs of the group to be more important than the needs of individuals.11

Characteristics of these two cultural styles are included in the table below. It is important to realize that not all of these characteristics relate to all people in a specific group; it provides a basic generalisation only.

With reference to the elements in the table consider the communication styles of the majority of Australians (individualists) versus that of Aboriginal and Torres Strait Islanders and other ethnic groups from collectivist societies and reflect on your encounters with these clients. Would you change your behaviour in any way to improve the encounter for both yourself and the client?

10 Leininger, M. (1991). Culture Care Diversity and Universality: A Theory of Nursing. New York. National League for Nursing Press. 11 Survival International, Annual Report (2003)


Types of culture

INDIVIDUALISM COLLECTIVISM

Individual is the focus. Goal is independence and

self-reliance

Focus on community. Focus on group rights over

individual rights. Sharing is a natural way of life;

things don’t belong to me, they belong to the

family.

Often barge in without getting to know someone.

Walk straight up to people, introduce myself and

start talking

May appear reserved – wait to be invited before

approaching new place or people. May be

reticent to make eye contact. Need to spend time

getting to know others; until I know and trust you I

may not tell you the full story (particularly relevant

when taking a medical history)

Direct explicit communication used to avoid

ambiguity

High use of non-verbal communication – ‘body

language’. Information is often implicit.

Direct communication often used without thought

of who is the appropriate person to receive

information.

Can speak to both men and women equally.

Indirectness valued. Direct confrontation often

rude or undesirable.

May not be able to speak or even be in the same

place as another person who has a specific kinship

relationship (avoidance)

Silence has low value Silence highly valued; allows time to think or to let

others speak

‘No’ is never a problem Reluctant to say ‘No’ for fear of offending. ‘Yes’

doesn’t necessarily mean yes (maybe I didn’t even

understand the question). If I disagree I may just

walk away

Value social power, status, prestige Value harmony, family security, sense of

belonging. My obligations to my family and social

relationships are very important and non-

negotiable; e.g. if there is a funeral I will need to

attend irrespective of work commitments or other

appointments

Independent decision making Consultation and consensus before decision

making; another family member or elder may relay

the decision. May not be appropriate for women

to speak out.


If health professionals have at least a basic understanding of different communication styles they should be aware of, and hopefully try to overcome, potential barriers to effective cross-cultural communication.

• Avoid making assumptions or judgements about individuals based on their communication style.

• Attempt to deliver information in culturally appropriate and targeted ways and assess the need for an interpreter or appropriate support person to assist.

• Appreciate the fact that many people from culturally and linguistically diverse (CALD) backgrounds need to involve family and community in discussions about health related issues.

• Demonstrate respect for ‘difference’ and check what is the most appropriate way to care for each person.

What are the implications for working in cross-cultural teams?

From a work perspective it may be important to determine how a team member’s culture and preferences impact on workplace behaviour. To leverage diversity within the team, members must be prepared to exercise tolerance for ambiguity, flexibility and try to understand the impact of cultural difference. Again, don’t make assumptions about colleagues based on stereotyping or your own personal biases. Ask if unsure!

A simple strategy to manage the negotiation of difference more effectively is to be aware of your responses and those of others and should include:

• Stop and suspend judgement – take another perspective “in the other person’s shoes”;


• Use your observation and listening skills – check your version of events with others “how does this look to you?”

• Recognise and respect difference – give others the chance to explain their understanding

• Find common ground and be flexible – be willing to try a new approach if you deem it safe.

Further reading (for interest only);

Mind Tools. (1995-2009). Hofstede's Cultural Dimensions: Understanding Workplace Values Around the World. Retrieved 21 April 2009, from http://www.mindtools.com/pages/article/newLDR_66.htm

Ganguly, I. (2001). The Third Dimension: cultural awareness for Non-English speaking background health professionals. Australian and New Zealand Journal of Public Health, 25(2), pages 109 -110.

Johnstone M-J, Kanitsaki O. (2005). Cultural Safety and Cultural Competence in Health Care and Nursing: An Australian Study. RMIT: Melbourne.

Working effectively with Aboriginal and Torres Strait Islander people

Aboriginal and Torres Strait Islander people view health as ‘not just the physical well-being of the individual but the social, emotional and cultural well-being of the whole community’12. The health status of Aboriginal and Torres Strait Islanders is well known and documented. The thirteenth biennial health report of the Australian Institute of Health and Welfare 2012 states:

“Aboriginal and Torres Strait Islander people generally fare worse on a number of health measures—for example, life expectancy is about 12 years shorter than for other Australians. And

12 National Aboriginal Health Strategy Working Party. 1989. Viewed 19th August 2014. http://www.ahmrc.org.au/index.php?option=com_content&view=article&id=35&Itemid=37


access to and use of health services is often lower—for example, in 2009–10, 36% of Indigenous women were screened for breast cancer, compared with 55% of non-Indigenous women”. 13

In 2004 the Australian Health Ministers’ Advisory Council (Standing Committee on Aboriginal and Torres Strait Islander Health Working Party) developed the Cultural Respect Framework for Aboriginal and Torres Strait Islander Health, 2004 – 2009 to provide a framework for culturally effective mechanisms to strengthen relationships between the Australian health care system setting and Aboriginal and Torres Strait Islander peoples across Australia. It was stated at the time that the health system, overall, does not provide the same level and quality of care to treat illness for Aboriginal and Torres Strait Islander peoples and is so culturally inappropriate or inadequately resourced that their needs cannot be met. Reasons given included availability and access to services, but it was evident that cultural factors such as health service provider attitudes and practice, communication issues, mistrust of the system, poor cultural understanding and racism were significant issues.14

The disproportionate burden of disease for Aboriginal and Torres Strait Islanders must be considered in the light of historical and political circumstances which include colonisation, genocide, oppression, social exclusion, western - informed health care, loss of land and people, sustained institutionalised racism and the devaluing of Indigenous knowledge, law, languages and culture. Cultural safety is considered to be a basic requirement for all health staff dealing with Aboriginal and Torres Strait Islander peoples and is an essential strategy to be used in attempts to improve communication with clients and therefore reduce preventable deaths. 15

Unfortunately many Non-Aboriginal people, whether consciously or unconsciously, have formed negative opinions about Aboriginal and Torres Strait Islander people. Sadly our biases are often founded on our quickness to pass judgment (based on our own cultural values), our personal interpretation of past experiences and/or other people’s uninformed views. And these common negative stereotypical assessments are reinforced often with media depictions of ‘hopeless’ Indigenous people.

How does this affect the way we view Aboriginal and Torres Strait Islander clients when they present at our health facilities?

In order to provide culturally safe health care to Aboriginal and Torres Strait Islander clients we need to reflect on our own cultural background, our beliefs and values, to understand how we perceive their cultural practices and beliefs. It is imperative that we build relationships based on mutual respect; only then will we gain trust and cooperation.

Consider the communication styles of Aboriginal and Torres Strait Islander in the context of ‘collectivist’ type culture we discussed earlier. Even if Aboriginal people speak English as a first language, serious comprehension difficulties can still occur due to the cultural differences that influence communication. Cultural influences on communication are complex and extensive, and an understanding of how perceptions - both Western and Indigenous - of health and

13 AIHW 2012. Australia's health 2012. Australia's health no. 13. Cat. No. AUS 156. Canberra: AIHW. Viewed 19th August 2014. http://www.aihw.gov.au/publication-detail/?id=10737422172 14 Australian Health Ministers’ Advisory Council. National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework 2011–2015. Viewed 19th August 2014. http://www.iaha.com.au/IAHA%20Documents/000172_National_ATSI_Health_workforce.pdf 15 Kruske S, Kildea S, Sherwood J. (2010) Working with Aboriginal and Torres Strait islander Women: providing maternity care. In: Advanced Life Support in Obstetrics course. ALSO Asia Pacific.


sickness are culturally constructed is essential to ensure effective clinical interactions. However, there is no ‘one way’ to communicate with any ethnic group and the same applies for Aboriginal and Torres Strait Islander peoples. Using a patient - centred approach, that is, treating each individual within the context of their cultural environment, is most appropriate. The Western Australia Centre for Rural Health Aboriginal Cultural Orientation package16 suggests that this can be achieved by:

• being respectful of the client’s cultural beliefs and practices; • providing the client with information in a language that they can understand; • facilitating the client’s decision making based on empowering them becoming ‘experts’

of his or her unique illness experience; • establishing partnerships among practitioners and families to ensure decisions are

according to patient needs and preferences; and, • addressing both disease (the physiological and psychological processes) and the illness

(the psychosocial processes meaning and the experience of the disease)

Watch this clip for some practical ideas when interacting with Aboriginal and Torres Strait Islander clients:

https://www.youtube.com/watch?v=dkPamrEcAkg

If we are all committed to providing culturally safe care what needs to happen for a health service to be considered ‘culturally secure or culturally competent’?

Cultural competence is defined as “a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross–cultural situations”. 17 It implies more than awareness of cultural differences, as it focuses on the capacity of the health system to improve health and well-being by integrating culture into the delivery of health services.

Implementation of culturally secure and competent health practices requires a multi-dimensional approach with action at systemic, organisational, professional and individual levels in appropriate cultural settings to increase the quality of health services; thereby producing better health outcomes. From a practical point of view this may include:

• Organisational strategic plans, policies and programs respond to the cultural needs of Aboriginal and Torres Strait Islander peoples

• Provide culturally responsive and flexible health services, including the involvement and support of Aboriginal and Torres Strait Islander staff, and inclusion of Aboriginal people on boards

16 Western Australia Centre for Rural Health Aboriginal Cultural Orientation http://lms.cucrh.uwa.edu.au/course/ 17 Australian Government National Health and Medical Research Council. 2006. Cultural Competency in Health: A guide for policy, partnerships and participation. Viewed 19th August 2014. https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/hp19.pdf


• Ensure an appropriately trained workforce • Cultural competency training must be provided for all staff • Value Aboriginal and Torres Strait Islander staff; mentor and support personal

development of Aboriginal staff. Seek their ideas about what they think would make the workplace more culturally appropriate.

• Interpreter services are sought when needed for safe and meaningful communication. • Provide separate spaces for privacy for men’s and women’s consultation • Respect the role of the family in decision making • Ensure the work space is welcoming – display appropriate posters or artwork • Make sure that there is information available about support services and how to access

them • Address any signs of racist attitudes or behaviour in a timely and appropriate manner • Value diversity • Adapt service delivery so that it reflects an understanding of the diversity between and

within cultures.

For individuals who intend to work with Aboriginal and Torres Strait Islanders, aim to actively pursue opportunities to increase your knowledge of local Aboriginal and Torres Strait Islander cultural practices and protocols. A commitment to cultural competence requires a willingness to gain the knowledge, understanding and skills to communicate sensitively and effectively with Aboriginal and Torres Strait Islander people and to acknowledge and respect cultural differences. Get to know your Aboriginal work colleagues; they will be your greatest support to ensure your practice is culturally appropriate.

Points to consider when working with Aboriginal Health Professionals (AHPs):

• AHPs are a valuable resource in the health centre team – recognise and respect them • ‘Front line’ of providing primary health care (PHC) to their communities and are the first

point of contact for many patients at an Aboriginal Medical Service • They have clinical skills and knowledge and can diagnose and treat a range of common

medical conditions • They are involved in helping to improve the health of people and communities on a

social, emotional, and political level as well as physical level • Be aware, supportive and flexible • AHPs are cultural brokers and coaches who can help you to develop less confronting

communication styles • Asking how to say something tells the AHP that you acknowledge that you do not know

how to do it and shows you are interested in developing the skills needed to communicate more effectively and develop relationships with Aboriginal clients

• Allow opportunities for listening • Make time to bond with your colleagues, don’t underestimate the invisible pressures on

them…it’s their community • Allow them to work at their pace, do not impose your values or expectations. Be aware

of not ‘shaming’ someone publicly • Be sensitive to avoidance relationships; there may be people they are not permitted

culturally to treat or even be in the same room with


• Observe protocols regarding Men’s and Women’s Business. It is preferable in most settings for a same-sex care provider. If not possible, get consent from the client for who is appropriate to provide treatment. 18

18 Adapted from presentation by Ree Dunn to staff at Katherine West Health Board, 2009


Cultural considerations in maternity care

Around a quarter of women who give birth in Australia were born in another country. These women experience slightly higher rates of fetal death than Australian-born women (7.9 versus 7.1 per 1,000 total births).19 Culture plays a major role in the way a woman perceives and prepares for her birthing experience. Each culture has its own values, beliefs and practices related to pregnancy and birth. Many women who come to Australia have a pragmatic attitude to traditional practices, and may not be interested in following them here. However, other women may consider it important to adhere to traditional pregnancy and birth practices. If health care providers are familiar with different ideas, rituals and behavioural restrictions and proscriptions, and communicate with the women for whom they care, then women from CALD backgrounds will have a choice. Provision of culturally safe care will ensure that individuals have the right to have their beliefs and value systems responded to sensitively and have all aspects of their religion, food, prayer, dress, privacy and customs respected.

Health professionals are not expected to know about the cultural practices of all the communities living in Australia. They are however, expected to use open communication, knowledge and respect when interacting with all clients. Woman-centred care focuses on the woman’s unique needs, expectations and aspirations; recognises her right to self-determination in terms of choice, control and continuity of care; and addresses her social, emotional, physical,

19 Laws PJ, Li Z, Sullivan EA (2010) Australia’s Mothers and Babies 2008. Perinatal statistics series no 24. Cat no PER 50. Canberra: Australian Institute of Health and Welfare. Viewed 18 August 2014 http://www.health.gov.au/internet/publications/publishing.nsf/Content/clinical-practice-guidelines-ac-mod1~part-a~population-groups~diverse-backgrounds


psychological, spiritual and cultural needs and expectations. 20 Be mindful that the potential for miscommunication and misunderstanding may be greater when seeing a woman from a CALD background. Women may subscribe to health beliefs which differ from the Australian health system and they may have different expectations about antenatal and maternity services.

There are some common issues that can affect uptake of antenatal care by women from culturally and linguistically diverse backgrounds. These include: 21

! language or lack of literacy; ! inaccessibility or unacceptability of health services; ! cultural issues regarding male health professionals; ! lack of usual female family and community support systems; ! conflict between traditional practices around antenatal care and mainstream health

services; ! lack of cultural competency among health professionals; ! history of grief, loss and trauma, in addition to migration; ! lack of entitlement to free health care; and ! lack of suitable resources (e.g. female interpreters).

Different cultural beliefs may also influence aspects of antenatal care such as involvement of the father in pregnancy and childbirth, consent for interventions such as caesarean section, willingness to be cared for by a midwife rather than a doctor, understanding of dates and times of appointments, and knowledge about medical aspects of pregnancy. Information needs to be explained carefully and clearly, with the assistance of an accredited interpreter, in addition to providing written information.

Many refugee and migrant women may feel fear of authority figures, including health professionals, due to past experiences of trauma and/or torture, and may also have financial, employment and housing issues. Women with a history of torture or trauma are at increased risk of mental disorders, including anxiety and depression; referral to appropriate counselling services should always be offered. Women in this situation will require reassurance and explanation of the care offered to them, including tests, procedures and pregnancy risks. More time may be needed, and specific strategies used (often in collaboration with other services and migrant agencies) to build necessary confidence and trust. They may also experience stress related to poor communication skills, the gender of health practitioners and an inability to comply with their cultural or religious practices (e.g. fasting, specific dietary requirements, headscarf or burqa).

20 Australian Nursing and Midwifery Council (ANMC). (2006). National competency standards for the Midwife. Viewed 19th August 2014. http://www.anmc.org.au/docs/Publications/Competency%20standards%20for%20the%20Midwife.pdf 21 McCarthy S & Barnett B (1996) Highlighting Diversity: NSW Review of Services for Non-English Speaking Background Women with Postnatal Distress and Depression, cited in http://www.health.gov.au/internet/publications/publishing.nsf/Content/clinical-practice-guidelines-ac-mod1~part-a~population-groups~diverse-backgrounds


Female Genital Mutilation (FGM) is increasingly an issue for health service providers in Australia, as the number of women affected by FGM who are accessing health services continues to grow. FGM is performed in a wide range of countries. Women who may be affected are usually from Africa (including Egypt, Eritrea, Ethiopia, Liberia, Somalia, Sudan, and Tanzania), and the Middle East and Asia (including Iraq, Oman, Pakistan, Syria, United Arab Emirates, Yemen). FGM is a complex issue and women affected by FGM need to be dealt with sensitively and in a culturally appropriate way.

Women affected by FGM may feel embarrassed to discuss FGM; they may be afraid of vaginal examination (usually prefer a female doctor), may believe that Australian doctors perform caesarean sections for all women with FGM, may not believe that the Australian health system knows how to provide care for women who have had FGM and may not feel comfortable with a team of doctors undertaking examinations. These women have specific care needs and should where possible be referred to experts in this field for ongoing support and management of their physical and psychological wellbeing. Health professionals are encouraged to develop an understanding of the issues facing mothers and babies from the culturally and linguistically diverse groups that they regularly work with and to use this information to improve the appropriateness of their care.

Factors that may improve the experience of maternity care for Aboriginal and Torres Strait Islander women include:

• taking the time to establish rapport and trust with each woman; • explaining confidentiality and that the woman’s privacy will be respected; • consulting the woman about whom she would like to be involved in her care; • having knowledge about the health and social wellbeing of the woman’s community;

and • if necessary, advocating on behalf of the woman so that she receives appropriate care

throughout pregnancy. 22

Aboriginal and Torres Strait Islander women may not have trust in the health service they are able to access (for all types of reasons). History and politics, as mentioned earlier, have led to the situation where Aboriginal and Torres Strait Islander peoples continue to be marginalised and suffer from much poorer health outcomes. Health professionals must acknowledge the power imbalance between client and health worker and attempt to lessen the impact through some practical measures:

22 Australian Government Department of Health. Clinical Practice Guidelines Antenatal Care. Module 1. Viewed 19th August 2014 http://www.health.gov.au/internet/publications/publishing.nsf/Content/clinical-practice-guidelines-ac-mod1~part-a~antenatal-care~woman-centred-care


• mindfulness about symbols of power (e.g. uniform, stethoscope) and the way the room is structured (e.g. avoiding sitting behind a desk);

• positioning — sitting alongside, not opposite, quiet or shy women and families; • showing genuine respect for the woman — the woman will be more likely to feel trust, tell

more of her experience and accept advice; • recognising that the woman has expertise and needs to be an active participant in decisions

about her care; that means we individualise care in partnership with her; • If possible ensure female caregivers are available and enable support people to be present

(allow the woman to decide who that will be); • use professional interpreters when possible to ensure full understanding of proposed care. 23

Summary

A brief clip to sum up the main points to consider when endeavouring to provide culturally sensitive and safe care:

http://www.youtube.com/watch?v=9u_r4ImdC3g&index=14&list=PL-BnrTdQ15sazEhL3Nw9uOzWYXlbg6F1b

23 Kruske S, Kildea S, Sherwood J. (2010) Working with Aboriginal and Torres Strait islander Women: providing maternity care. In: Advanced Life Support in Obstetrics course. ALSO Asia Pacific.


The crucial ingredient for providing culturally safe and competent maternity care to culturally

diverse clients and co-workers is RESPECT:

• Being respectful of differences and diversity

• Being aware of history, cultural preferences and how these impact on a person’s interaction with health services

• Being mindful of the power relationships occurring in the interaction

• Being open and honest with clients; ask if unsure, don’t make assumptions based on your biases

REMEMBER: cultural safety is determined by the person receiving the care.

References:

Quappe, S., Cantatore, G. 2005. ‘What is Cultural Awareness, anyway? How do I build it?’ Viewed August 18th 2014 http://www.culturosity.com/articles/whatisculturalawareness.htm National Aboriginal Community Controlled Health Organisation. May 2011. ‘NACCHO Cultural Safety Training Standards: A background paper’, p.10. Viewed 19th August 2014. http://www.naccho.org.au/download/cultural_safety/CSTStandardsBackgroundPaper.pdf

Nursing Council of New Zealand. (March 2002). ‘Guidelines for Cultural Safety, the Treaty of Waitangi, and Maori Health in Nursing and Midwifery Education and Practice’. Viewed 19th August 2014. http://nursingcouncil.org.nz/About-us/Treaty-of-Waitangi

Australian Health Ministers’ Advisory Council - Standing Committee on Aboriginal and Torres Strait Islander Health Working Party, AHMAC Cultural Respect Framework for Aboriginal and Torres Strait Islander Health, 2004 – 2009, AHMAC 2004. Viewed 19th August 2014 http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-oatsih-pubs-crf.htm; National Health and Medical Research Council 2006, Cultural Competency in Health: A Guide for policy, partnerships and participation, Commonwealth of Australia, Canberra. Viewed 18th August 2014. http://www.lowitja.org.au/congress-2014/workshops/cultural-competency#sthash.D42S8wX.dpuf Queensland Government. ‘Queensland Health Strategic Plan for Multicultural Health 2007- 2012’. Viewed 18th August 2014. http://www.health.qld.gov.au/multicultural/contact_us/framework.asp NSW Government. ‘Policy and Implementation Plan for Healthy Culturally Diverse Communities 2012–2016’. Viewed 18th August, 2014. http://www.mhcs.health.nsw.gov.au/policiesandguidelines/pdf/policy-and-implementation-plan-for-healthyculturallydiverse2012-2016.pdf


Victorian Health Promotion Foundation (VicHealth). ‘Building on our strengths. A framework to reduce race-based discrimination and support diversity in Victoria. Summary report’. Viewed 19th August 2014. http://www.vichealth.vic.gov.au/~/media/ProgramsandProjects/Publications/Attachments/Building_on_our_strengths_Summary.ashx Iceberg Concept of Culture https://www.google.com/search?q=iceberg%20concept%20of%20culture&gws_rd=ssl&tbm=isch

Leininger, M. (1991). Culture Care Diversity and Universality: A Theory of Nursing. New York. National League for Nursing Press. Survival International, Annual Report (2003) National Aboriginal Health Strategy Working Party. 1989. Viewed 19th August 2014. http://www.ahmrc.org.au/index.php?option=com_content&view=article&id=35&Itemid=37 Australian Institute of Health and Welfare (AIHW) 2012. Australia's health 2012. Australia's health no. 13. Cat. No. AUS 156. Canberra: AIHW. Viewed 19th August 2014. http://www.aihw.gov.au/publication-detail/?id=10737422172 Australian Health Ministers’ Advisory Council. National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework 2011–2015. Viewed 19th August 2014. http://www.iaha.com.au/IAHA%20Documents/000172_National_ATSI_Health_workforce.pdf Kruske S, Kildea S, Sherwood J. (2010) Working with Aboriginal and Torres Strait islander Women: providing maternity care. In: Advanced Life Support in Obstetrics course. ALSO Asia Pacific. Western Australia Centre for Rural Health Aboriginal Cultural Orientation package http://lms.cucrh.uwa.edu.au/course/ Australian Government National Health and Medical Research Council. 2006. Cultural Competency in Health: A guide for policy, partnerships and participation. Viewed 19th August 2014. https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/hp19.pdf Dunn, M. 2009. Orientation Package Katherine West Health Board, Northern Territory. Laws PJ, Li Z, Sullivan EA (2010) Australia’s Mothers and Babies 2008. Perinatal statistics series no 24. Cat no PER 50. Canberra: Australian Institute of Health and Welfare. Viewed 18 August 2014 http://www.health.gov.au/internet/publications/publishing.nsf/Content/clinical-practice-guidelines-ac-mod1~part-a~population-groups~diverse-backgrounds Australian Nursing and Midwifery Council (ANMC). (2006). National competency standards for the Midwife. Viewed 19th August 2014. http://www.anmc.org.au/docs/Publications/Competency%20standards%20for%20the%20Midwife.pdf McCarthy S & Barnett B (1996) Highlighting Diversity: NSW Review of Services for Non-English Speaking Background Women with Postnatal Distress and Depression, cited in http://www.health.gov.au/internet/publications/publishing.nsf/Content/clinical-practice-guidelines-ac-mod1~part-a~population-groups~diverse-backgrounds

Australian Government Department of Health. Clinical Practice Guidelines Antenatal Care. Module 1. Viewed 19th August 2014 http://www.health.gov.au/internet/publications/publishing.nsf/Content/clinical-practice-guidelines-ac-mod1~part-a~antenatal-care~woman-centred-care

This resource was compiled by Maree (Ree) Dunn RN RM MPH&TM for CRANAplus National Education Program.

August 2014

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