CPD for clinical support roles: Providing culturally safe practice

Abstract
Background: Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them.

Methods: A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Māori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa - Māori Medical Practitioners Association (Te ORA) and consultation with Māori medical practitioners via Te ORA.

Results: Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the 'taken for granted' power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming 'competent' in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity.

Conclusions: A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important.

Abstract
Cultural safety is increasingly being taught in tertiary programmes of study for health professionals. Reflexivity is a key skill required to engage in culturally safe practice, however, there is currently limited literature examining how reflexivity is taught or assessed within cultural safety curricula. A systematic review of the literature up until November 2021 was conducted, examining educational interventions which aimed to produce culturally safe learners. Studies were limited to those with a focus on Indigenous health and delivered in Australia, Aotearoa New Zealand, Canada, and the United States. A total of 46 documents describing 43 different educational interventions were identified. We found that definitions and conceptualisations of reflexivity varied considerably, resulting in a lack of conceptual clarity. Reflexive catalysts were the primary pedagogical approaches used, where objects, people, or Indigenous pedagogies provided a counterpoint to learners' knowledges and experiences. Information regarding assessment methods was limited but indicates that the focus of existing programmes has been on changes in learner knowledge and attitudes rather than the ability to engage in reflexivity. The results demonstrate a need for greater conceptual clarity regarding reflexivity as it relates to cultural safety, and to develop methods of assessment that focus on process rather than outcomes.

Abstract
Background: Racism is increasingly recognised as a significant health determinant that contributes to health inequalities. In Australia efforts have been made to bridge the recognised health gap between Aboriginal and Torres Strait Islander people and other Australians. This systematic scoping review aimed to assess, synthesise, and analyse the evidence in Australia about the impacts of racism on the mental and physical health of Aboriginal and Torrens Strait Islander peoples.

Methods: A systematic search was conducted to locate Australian studies in English published between 2000 and 2020. Five electronic databases were used: PubMed, CINAHL, Embase, Web of Science and the Australia's National Institute for Aboriginal and Torres Strait Islander Health Research. The search strategy included a combination of key words related with racism, mental health, physical health and Indigenous people. Data were extracted based on review questions and findings were synthesized in a narrative summary.

Results: Of total 338 searched studies from five databases, 12 studies met the inclusion criteria for narrative synthesis where eight were cross-sectional studies and four prospective cohorts. General mental health and general health perception were the most frequently studied outcomes followed by child behaviour, smoking and substance consumption and specific health conditions. The prevalence of racism varied between 6.9 and 97%. The most common health outcomes associated with racism were general poor mental health and poor general health perception. More specific health outcomes such as anxiety, depression, child behaviour, asthma, increased BMI and smoking were also associated with racism but were analysed by a limited number of studies. Three studies analysed psychological distress, negative mental health, sleeping difficulties and negative perceived mental health according to severity of exposition to racism.

Conclusion: Racism is associated with negative overall mental and negative general health outcomes among Aboriginal and Torres Strait Islander peoples. Strategies to prevent all forms and sources of racism are necessary to move forward to bridging the health gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians. Further research is needed to understand in more detail the impact of racism from an Aboriginal and Torres Strait Islander definition of health and wellbeing.

Abstract
Background: Racism is an underlying cause of ethnic health inequities both in Aotearoa New Zealand and internationally. It is timely to synthesise racism and health research within New Zealand particularly given the current policy environment and shift towards addressing the health effects of racism.

Aim: To review quantitative research examining self-reported experiences of racial discrimination and associations with measures of health (health conditions, health risk, health status and healthcare) in New Zealand.

Methods: MEDLINE, PsycINFO, Web of Science and CINAHL databases were searched for studies reporting on associations between experiences of racism and health.

Results: The systematic review identified 24 quantitative studies reporting associations between self-reported racial discrimination across a wide range of health measures including mental health, physical health, self-rated health, wellbeing, individual level health risks, and healthcare indicators.

Conclusions: Quantitative racism and health research in New Zealand consistently finds that self-reported racial discrimination is associated with a range of poorer health outcomes and reduced access to and quality of healthcare. This review confirms that experience of racial discrimination is an important determinant of health in New Zealand, as it is internationally. There is a pressing need for effectively designed interventions to address the impacts of racism on health.

Abstract
Discrimination is a fundamental determinant of health and health inequities. However, despite the high prevalence of discrimination exposure, there is limited evidence specific to Indigenous populations on the link between discrimination and health. This study employs a validated measure to quantify experiences of everyday discrimination in a national sample of Aboriginal and Torres Strait Islander (Australia's Indigenous peoples) adults surveyed from 2018 to 2020 (≥16 years, n = 8108). It quantifies Prevalence Ratios (PRs) and 95% Confidence Intervals (CIs) for wellbeing outcomes by level of discrimination exposure, and tests if associations vary by attribution of discrimination to Indigeneity. Of the participants, 41.5% reported no discrimination, 47.5% low, and 11.0% moderate-high. Discrimination was more commonly reported by younger versus older participants, females versus males, and those living in remote versus urban or regional areas. Discrimination was significantly associated in a dose-response manner, with measures of social and emotional wellbeing, culture and identity, health behaviour, and health outcomes. The strength of the association varied across outcomes, from a 10-20% increased prevalence for some outcomes (e.g., disconnection from culture (PR = 1.08; 95% CI: 1.03, 1.14), and high blood pressure (1.20; 1.09, 1.32)), to a five-fold prevalence of alcohol dependence (4.96; 3.64, 6.76), for those with moderate-high versus no discrimination exposure. The association was of consistent strength and direction whether attributed to Indigeneity or not-with three exceptions. Discrimination is associated with a broad range of poor wellbeing outcomes in this large-scale, national, diverse cohort of Aboriginal and Torres Strait Islander adults. These findings support the vast potential to improve Aboriginal and Torres Strait Islander peoples' wellbeing, and to reduce Indigenous-non-Indigenous inequities, by reducing exposure to discrimination.

The website also hosts the Workplace Cultural Diversity Tool, a free, online, confidential self-assessment tool for organisations seeking to strengthen their approach to cultural diversity and anti-racism in the workplace.

Panel discussion on how the AMC has used a ‘shared sovereignty process which acknowledges the right to self-determination for developing Aboriginal, Torres Strait Islander and Māori health and cultural safety related content’.