Monitoring framework

The Cultural safety in health care for Indigenous Australians: monitoring framework is structured around three modules: Module 1 – Culturally respectful health care services; Module 2 – Patient experience of health care; and Module 3 – Access to health care services. Each of the three modules contains a number of domains, focus areas and measures, with the following structure:

Module → domain → focus area → measure

The three modules look at different dimensions of cultural safety—how health care is provided, experienced and accessed. The domains are topics within the modules; focus areas look at specific issues in the domains; and measures describe the data presented in the focus areas.

The modules and their domains are set out below.

Module 1: Culturally respectful health care services

  • Organisational approach and commitment
  • Communication and cultural services
  • Workforce development and training
  • Consumer engagement and stakeholder collaboration

Module 2: Patient experience of health care

  • Communication
  • Treated respectfully
  • Unfair treatment and cultural barriers
  • Empowerment
  • Family inclusion
  • Leave events

Module 3: Access to health care services

  • Preventive health services
  • Primary health care
  • Hospital services
  • Specialist services
  • Overall health system

Origin and policy context

The concept of cultural safety has been around for some time, with the notion originally defined and applied in the cultural context of New Zealand. It originated there in response to the harmful effects of colonisation and the ongoing legacy of colonisation on the health and healthcare of Maori people—in particular in mainstream health care services.

A commonly accepted definition of cultural safety from the Nursing Council of New Zealand (2005: 7) is the ‘effective nursing practice of a person or family from another culture, and is determined by that person or family… Unsafe cultural practice comprises any action which diminishes, demeans or disempowers the cultural identity and wellbeing of an individual.’

A distinctive feature of this definition of cultural safety is its emphasis on the provision of culturally safe health care services as defined by the end users of those services, notably, the Maori people of Aotearoa New Zealand, not by the (non-Maori) providers of care.

The National Collaboration Centre for Indigenous Health in Canada (2013) notes that culturally safe health care systems and environments are established by a continuum of building blocks:

Cultural awareness ⟹

Cultural sensitivity ⟹

Cultural competency ⟹

Cultural safety

The centre states that cultural safety ‘…requires practitioners to be aware of their own cultural values, beliefs, attitudes and outlooks that consciously or unconsciously affect their behaviours. Certain behaviours can intentionally or unintentionally cause clients to feel accepted and safe, or rejected and unsafe. Additionally cultural safety is a systemic outcome that requires organizations to review and reflect on their own policies, procedures, and practices in order to remove barriers to appropriate care.’

In Australia, there has been increasing recognition that improving cultural safety for Aboriginal and Torres Strait Islander health care users can improve access to, and the quality of health care. This means a health system where Indigenous cultural values, strengths and differences are respected; and racism and inequity is addressed.

There are difficulties in both defining and measuring generalised concepts such as cultural respect and cultural safety. They include lack of conceptual clarity and agreement on terms, the qualitative nature of the concepts, and the diversity of Indigenous Australians and their perceptions. The Australian literature uses various definitions of cultural safety, and related concepts such as cultural respect and cultural competency, and what these mean in relation to the provision of health care.

For the purpose of developing a monitoring framework cultural safety is defined with reference to the experience of the Indigenous health care consumer, of the care they are given, their ability to access services and to raise concerns. Some of the essential features of cultural safety include an understanding of one’s culture; an acknowledgment of difference, and a requirement that caregivers are actively mindful and respectful of this difference; and the ability to recognise, address and prevent racism. The presence or absence of cultural safety is determined by the experience of the recipient of care and is not defined by the caregiver (AHMAC 2016).

Two important aspects of culturally safe health care across the literature are, how it is provided and how it is experienced, and these form the basis for the monitoring framework (see AHMAC 2016; CATSINAM 2014; AIDA 2017; DHHS 2016; NACCHO 2011; Department of Health 2015).

How health care is provided

  • behaviour, attitude and culture of providers: respects and understands Indigenous culture and people
  • defined with reference to the provision of care, including governance structures, policies and practices
  • providers' ability to recognise, address and prevent racism at the individual and organisational levels.

How health care is experienced by Indigenous people

  • feeling safe, connected to culture and cultural identity is respected
  • can only be defined by those who receive health care.

The importance of cultural respect and cultural safety is outlined in Australian government documents such as the:

The new health plan was developed in genuine partnership with Aboriginal and Torres Strait Islander people and reflects their key priorities and recognises the influence of social factors and the strengths of culture as protective factors on physical, social and emotional wellbeing.

The Australian Commission on Safety and Quality in Healthcare (ACSQHC) also included six Aboriginal and Torres Strait Islander specific actions in the PDF DownloadNational Safety and Quality Health Service Standards to improve care for Aboriginal and Torres Strait Islander people in mainstream health services.

Development of a monitoring framework

The Cultural safety in health care for Indigenous Australians: monitoring framework aims to measure progress in achieving cultural safety in the Australian health system by bringing together data related to cultural safety. Specifically, to measure progress in achieving cultural safety in the health system under the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–23. The framework can also assist in measuring progress in achieving cultural safety under the Cultural Respect Framework which commits the Commonwealth Government, and states and territories, to embed cultural respect principles into their health systems; from developing policy and legislation, to how organisations are run, through to the planning and delivery of services.

The release of the 2020–2031 National Agreement on Closing the Gap necessitated revisions to the National Aboriginal and Torres Strait Islander Health Plan 2013–2023, in order for the Health Plan to be aligned with the objectives and timeframes of the National Agreement. Following the release of the National Aboriginal and Torres Strait Islander Health Plan 2021–2031 the Implementation Plan will be revised and a new accountability framework will be created.

In consultation with key stakeholders, including the former National Aboriginal and Torres Strait Islander Health Standing Committee and the Implementation Plan Advisory Group, this monitoring framework was developed through a review of relevant policy documents, academic literature, and potential national and state level data sources.

The framework has 3 reporting modules which each include a range of measures focusing on culturally respectful health care services, patient experience of health care among Indigenous Australians, and access to health care as an indirect measure of cultural safety.

Reporting against the framework

This monitoring framework brings together available national and state and territory level data to provide a picture of cultural safety in the health system. The scope of national and state and territory level data currently available are limited and further development is required to enable more comprehensive reporting. For more detail see information about data gaps in Module 1: Culturally respectful health care services, Module 2: Patient experience of health care, and Module 3: Access to health care services.

Monitoring cultural safety and cultural respect in the health system, and the impact it has on access to appropriate health care, are limited by a lack of national and state level data. This is particularly the case in relation to reporting on the policies and practices of mainstream health services, such as primary health care services.

There are also limited data on the experiences of Indigenous health care users. Most jurisdictions undertake patient experience surveys in public hospitals, but there is little data on Indigenous Australians for reporting. A high proportion of Indigenous Australians use mainstream health services, so further data developments in this area are required to allow for more comprehensive reporting across the health sector.

As data developments occur and more comprehensive data become available, the cultural safety monitoring framework will be expanded and updated.

Relevant data developments

Data development for cultural safety measures are ongoing. There are also research and developments in measurement of areas related to cultural safety, such as wellbeing and quality of life.

One such project is the What Matters 2 Adults study, which aims to develop a new instrument to measure and value wellbeing dimensions that are important to Indigenous Australians.

Another example is the Mayi Kuwayu study, a national longitudinal survey of Indigenous Australians aged 16 years and above. It began in 2018, and could provide relevant data on cultural safety in the future. This survey, which was created by and for Indigenous people, focuses on the importance of culture and how it affects wellbeing, and includes a module on discrimination and racism in health care. Initial results from the study and the validity of the instrument used to measure discrimination in health care experienced by Indigenous Australians are discussed in the paper, Developing and validating measures of self-reported everyday and healthcare discrimination for Aboriginal and Torres Strait Islander adults.

There have been a number of publications released by the Mayi Kuwayu team, and they will be linked to in the relevant domains within the monitoring framework.

Indigenous patients’ experiences of health care could be reported through Patient Reported Experience Measures (PREMs) and Patient Reported Outcome Measures (PROMs) surveys. The collection of patient reported data through standardised PREMs and PROMs for Indigenous health care users’ needs to consider the cultural adaptability of these tools and development work is underway to address this at hospital and primary health care service level.