Health care provider and consumer understandings of cultural safety and cultural competency in health care : an Australian study

There is increasing recognition in Australia that racial and ethnic minority groups experience significant disparities in health and health care compared with the average population and that the Australian health care system needs to be more responsive to the health and care needs of these groups. The paper presents the findings of a year long study that explored what providers and recipients of health care know and understand about the nature and implications of providing culturally safe and competent health care to minority racial and ethnic groups in Victoria, Australia. Analysis of the data obtained from interviewing 145 participants recruited from over 17 different organizational sites revealed a paucity of knowledge and understanding of this issue and the need for a new approach to redress the status quo.

An exploration of the notion and nature of the construct of cultural safety and its applicability to the Australian health care context

Cultural safety has been promoted by its New Zealand proponents as an effective process for managing cultural risk in health care and improving the cultural responsiveness of mainstream health services when delivering care to culturally diverse populations. Its effectiveness in this regard has not, however, been comprehensively investigated. A key purpose of this study was to explore and describe what is known and understood about the notion of cultural safety and its possible application to and in Australian health care domains. Findings from the study indicate that the notion of cultural safety is conceptually problematic, poorly understood, and underresearched and, unless substantially revised, cannot be meaningfully applied to the cultural context of Australia.

Cultural racism, language prejudice and discrimination in hospital contexts : an Australian study

This article explores the idea that racial and ethnic disparities in healthcare may be expressive of unacknowledged practices of cultural racism. In conducting this exploration, the researchers identify, describe and discuss the practice of language prejudice and discrimination by health service providers, discovered serendipitously in the context of a broader study exploring cultural safety and cultural competency in an Australian healthcare context. The original study involved individual and focus groups interviews with 145 participants recruited from over 17 different organisational and domestic home sites. Participants included health service managers, ethnic liaison officers, qualified health interpreters, cultural trainers/educators, ethnic welfare organisation staff, registered nurses, allied health professionals, and healthcare consumers. Participants self-identified as being from over 27 different ethnocultural and language backgrounds.

Analysis of the data revealed that English language proficiency, like skin colour, was used as a social marker to classify, categorise, and negatively evaluate people of non-English speaking backgrounds (NESB) in the contexts studied. Negative evaluations, in turn, were used to justify the exclusion of NESB people from healthcare relationships and resources. Further data analysis revealed that underpinning the negative attitudes and behaviours in hospital domains concerning people who spoke accented English or who did not speak English proficiently were a dislike of difference, fear of difference, intolerance of difference, fear of competition for scarce healthcare resources, repressed hostility toward difference, and ignorance.

Highlighting the implications of language prejudice for the safety and quality care of NESB people, the researchers call for further internationally comparative research and debate on the subject.

Generation of statements for the development of clinical indicators for mental heath nursing in New Zealand : achieving a bicultural focus

Aim : In this paper, the first of 4 stages of a large study aiming to develop culturally and clinically valid clinical indicators to flag the achievement of mental health nursing standards of practice in New Zealand are described.

Methods : A bicultural design was employed throughout the research project to ensure that nurses' views of practice and the cultural differences between New Zealand's indigenous Maori and non-Maori peoples could be identified. Accordingly, separate focus groups of Maori- and non-Maori-experienced mental health nurses were asked to develop lists of statementd reflective of the Australian and New Zealand College of Mental Health Nurses' Standards of Practice in New Zealand.

Results : The focus group participants produces 473 statements, which were synthesized into 190 clinical indicator statements. In keeping with the bicultural research design, Maori and non-Maori data were analysed separately until the data were merged to provide a single set of indicator statements. Although both Maori and non-Maori groups wrote statements relevant to clinical practice, there was a difference in the way the 2 groups addressed cultural issues. The Maori focus group wrote statements about cultural issues for 4 of the 6 Standards of Practice, whereas the non-Maori focus group participants wrote statements about cultural issues for only the Standard focusing on cultural safety.

Conclusion : The research design of this project in mental health nursing was unique in that it sought the perspectives of both indigenous and non-indigenous nurses about quality mental health nursing practice related to the professional standards of practice. The involvement of Maori and non-Maori mental health nurses enhanced the cultural and clinical validity of the study and the obtained from it. The bicultural approach adopted for the study highlights the need for more mental health nursing research involving indigenous partners.

Inclusion in participatory research: what were the whitefellas doing in an Aboriginal health project?

Health research in indigenous communities, like many interactions between such communities and white-dominated institutions, has a chequered history leading to a three-fold decrement: suspicion and resistance to research that is seen as coming from outside of the community; a shortage of research generators and leaders within the community; and cumulative gaps in the research evidence base, both in terms of coverage of topics and in terms of meeting the priorities of the community.

Additionally, these decrements have been mistakenly located as problems being caused from within the community, rather than recognising that these are outcomes of wider contextual, historical and institutional factors and failings. Good research, as culturally appropriate, inclusive of community voices and meeting the needs and priorities of the community, is necessary in an increasingly evidence-based-practice culture within policy and health settings. Culturally safe research with and for indigenous communities has the potential to be empowering, and to bring community voices, views and experiences into the influential realm of'evidence.

This process of developing safe, appropriate and inclusive research is not straightforward: the decrements are recursive, with a shortage of connections between the community, its priorities and research. However, as the Healing Stories project that we discuss here has shown, it is possible to develop culturally safe participatory research by working with Elders from within the community and with leaders from within white institutions, in a spirit of reconciliation. The methods and findings of Healing Stories have been reported elsewhere, with an emphasis on the voices from the community; this chapter explores some of the 'behind the scenes' processes, from the perspective of the white researchers working from within white- dominated institutions.

After briefly describing the Healing Stories project, this chapter reflects on three parts of the participatory research process: getting started, leading together, and working together. The first of these considers laying the foundations for participatory research, working with Elders and leaders, and planning for inclusion, examining participatory research as a recognisable research design, with potential for rigour, cultural safety and inclusion. The second explores developing participatory methods, working with communities, and opportunities and choices for inclusion. The third examines the process of being participatory, working together and engaging in inclusion across the long-term commitment to the project.

Music therapy and medical ethnomusicology: distinctive and connected

A music therapist and an ethnomusicologist who is also qualified as a music therapist explore some of the ways in which music therapy and medical ethnomusicology might engage a dialogue that is helpful to expanding thinking and practice in both fields. We begin by describing music therapy and outlining some core concepts of therapeutic work. We then discuss ethnomusicology and reflect on the ways in which music therapy and ethnomusicology may complement one another in the field of medical ethnomusicology. We consider how an exploration of concepts informing cultural safety might be enacted in healthcare through the use of music and whether this might serve as a useful joint future enterprise between music therapists and medical ethnomusicologists. Finally we explain why we encourage medical ethnomusicologists to cease attempts to become applied therapeutic practitioners without further therapy skills training.

Engaging patients as safety partners : some considerations for ensuring a culturally and linguistically appropriate approach

Engaging patients as ‘safety partners’ with health service providers to help identify and rectify preventable adverse events in health care is being increasingly accepted in the USA, Australia, and elsewhere as a promising strategy to improve patient safety outcomes. The implications of this trend for patients and families of minority cultural and language backgrounds have not, however, been comprehensively considered. In this article, attention is given to briefly exploring the notion of patient participation in health care and the problematic transposition of the concept into patient safety discourse. The importance of recognising and responding to the critical relationship between culture, language and
patient safety outcomes, and the possible benefits and risks of engaging patients of minority ethnic backgrounds in safety partnership programs are explored. It is suggested that if patient safety engagement/partnership programs are to perform well in cross-cultural health care contexts, they need to be supported by research evidence and appropriately informed by the perspectives and experiences of patients and families/nominated carers from minority cultural and language backgrounds. They also need to be appropriately supported by culturally competent policies and practices across the entire health care system. The importance of robust internationally comparative research on this issue is highlighted.

Domestic violence and the exemption from seeking child support : providing safety or legitimizing ongoing poverty and fear

This article examines the experience of low-income women on welfare in Australia and the process of seeking child support from a violent ex-partner, contrasting this with research from the United States and the United Kingdom. Women in Australia who fear ongoing or renewed abuse as a result of seeking child support are eligible for an exemption. However, the exemption policy does not necessarily provide the intended protection of women and children from ongoing abuse and poverty. The exemption policy route also produces an unintended outcome whereby the perpetrators of violence are financially rewarded as they do not have to pay child support. These outcomes are shaped by a complex interaction of personal, cultural and structural forces that make the process of seeking child support for women who have experienced violence extremely problematic. The article demonstrates how in Australia, as in the US and UK policy contexts, the needs of women and their children are compromised by the details of policy specification and the way policies are implemented within the different systems.

Culture, language, and patient safety : making the link

It has been well recognized internationally that hospitals are not as safe as they should be. In order to redress this situation, health care services around the world have turned their attention to strategically implementing robust patient safety and quality care programmes to identify circumstances that put patients at risk of harm and then acting to prevent or control those risks. Despite the progress that has been made in improving hospital safety in recent years, there is emerging evidence that patients of minority cultural and language backgrounds are disproportionately at risk of experiencing preventable adverse events while in hospital compared with mainstream patient groups. One reason for this is that patient safety programmes have tended to underestimate and understate the critical relationship that exists between culture, language, and the safety and quality of care of patients from minority racial, ethno-cultural, and language backgrounds. This article suggests that the failure to recognize the critical link between culture and language (of both the providers and recipients of health care) and patient safety stands as a ‘resident pathogen’ within the health care system that, if not addressed, unacceptably exposes patients from minority ethno-cultural and language backgrounds to preventable adverse events in hospital contexts. It is further suggested that in order to ensure that minority as well as majority patient interests in receiving safe and quality care are properly protected, the culture–language–patient-safety link needs to be formally recognized and the vulnerabilities of patients from minority cultural and language backgrounds explicitly identified and actively addressed in patient safety systems and processes.

Total safety culture by behavior-based safety approach

Safety is a social responsibility and providing a safe working environment is the obligation of a responsible employer. Working safely can generate direct financial benefits. However, poor safety planning and management may lead to tremendous adverse effects on cost, time and quality of a project. Statutory liabilities and heavy fines directly increase project cost; losing working hours as a result of safety incident impacts on the project programme. When tradesmen are working in an unsafe site environment, the project quality may be affected. Therefore, promoting "safety" is always the very first and utmost priority in any large scale projects. Bodley (2000) argues that culture involves what people think, what they do, and what they produce. In order to provide a safe working environment, one of the best ways is to create a safety culture within the organization, because organizational-cultural factors play an important role in safety management. Geller emphasises the importance of safety culture and further states that behaviour-based safety (BBS) is a useful approach to uphold organizational safety culture. The basic premise of BBS is self-perception and the degree of self-perception will lead to pleasant safety outcomes. This degree can be measured by level of workers' involvement. When everyone in the project is accountable to safety, they will contribute positively. This paper is a case study reviewing how BBS approach fosters safety culture leading to ultimate success. The model illustrated by the case study will be useful to analyze the organizational safety culture quantitatively.

You say security, we say safety : speaking and talking ‘security’ in Kyrgyzstan

The Copenhagen School's notion of securitization is widely recognised as an important theoretical innovation in the conceptualisation of security, not least for its potential for including a range of actors and spatial scales beyond the state. However, its empirical utility remains more open to question due to a lack of reflexivity regarding local socio-cultural contexts, narrow focus on speech and inherently retrospective nature. Drawing on fieldwork conducted by the author in Kyrgyzstan between September 2005 and June 2006, this paper will examine the implications of these limitations for conducting empirical research on "security" logistically and methodologically. Centrally, the question of how “security” can be researched in the field will be discussed. Consideration will be given to the researcher’s role in talking “security” and how “security” can effectively be located and explicated through the creation of ethnomethodological “thick description”. Issues of contingency, multiple voices and power loci, and inter-cultural translation will be addressed. The paper will conclude with a consideration of how local knowledge can be used to inform our research and help find ways to bridge the divide between the field and theory.

Occupational health and safety among commercial sex workers

The concept of occupational health and safety (OHS) for commercial sex workers has rarely been investigated, perhaps because of the often informal nature of the workplace, the associated stigma, and the frequently illegal nature of the activity. We reviewed the literature on health, occupational risks, and safety among commercial sex workers. Cultural and local variations and commonalities were identified. Dimensions of OHS that emerged included legal and policing risks, risks associated with particular business settings such as streets and brothels, violence from clients, mental health risks and protective factors, alcohol and drug use, repetitive strain injuries, sexually transmissible infections, risks associated with particular classes of clients, issues associated with male and transgender commercial sex workers, and issues of risk reduction that in many cases are associated with lack of agency or control, stigma, and legal barriers. We further discuss the impact and potential of OHS interventions for commercial sex workers. The OHS of commercial sex workers covers a range of domains, some potentially modifiable by OHS programs and workplace safety interventions targeted at this population. We argue that commercial sex work should be considered as an occupation overdue for interventions to reduce workplace risks and enhance worker safety.

Occupational safety in China: safety climate and its influence on safety-related behavior

The improvement of health and safety standards within the organizational context is an important issue of global concern. China’s occupational health and safety (OHS) has increasingly drawn national and international attention as it has not kept pace with its globalization of production and trade. The traditional approach to managing workplace safety in China has focused on the technical aspects of engineering systems and processes, and it has attributed the majority of workplace accidents and injuries to unsafe working conditions instead of the unsafe work practices of employees. However, there has been a fundamental shift in the safety management research carried out in many countries and across diverse industries, which aims to measure the impact of attitudinal, organizational, cultural, and social dimensions on occupational safety. This article examines the relationship between safety climate and safety-related behavior in the Chinese context and draws implications for the management of occupational safety in China.

Building Nature’s Safety Net 2014 : A decade of protected area achievements in Australia

The single most important asset for the conservation of Australia’s unique and globally significant biodiversity is the National Reserve System, a mosaic of over 10,000 discrete protected areas on land on all tenures: government, Indigenous and private,including on-farm covenants, as well as state, territory and Commonwealth marine parks and reserves.THE NATIONAL RESERVE SYSTEMIn this report, we cover major National Reserve System initiatives that have occurred in the period 2002 to the present and highlight issues affecting progress toward agreed national objectives. We define a minimum standard for the National Reserve System to comprehensively, adequately and representatively protect Australia’s ecosystem and species diversity on sea and land. Using government protected area, species and other relevant spatial data, we quantify gaps: those areas needing to move from the current National Reserve System to one which meets this standard. We also provide new estimates of financial investments in protected areas and of the benefits that protected areas secure for society. Protected areas primarily serve to secure Australia’s native plants and animals against extinction, and to promote their recovery.BENEFITSProtected areas also secure ecosystem services that provide economic benefits forhuman communities including water, soil and beneficial species conservation, climatemoderation, social, cultural and health benefits. On land, we estimate these benefitsare worth over $38 billion a year, by applying data collated by the Ecosystem ServicesPartnership. A much larger figure is estimated to have been secured by marineprotected areas in the form of moderation of climate and impact of extreme eventsby reef and mangrove ecosystems. While these estimates have not been verified bystudies specific to Australia, they are indicative of a very large economic contributionof protected areas. Visitors to national parks and nature reserves spend over $23.6 billion a year in Australia, generating tax revenue for state and territory governments of $2.36 billion a year. All these economic benefits taken together greatly exceed the aggregate annual protected area expansion and management spending by all Australian governments, estimated to be ~$1.28 billion a year. It is clear that Australian society is benefiting far greater than its governments’ investment into strategic growth and maintenance of the National Reserve System.Government investment and policy settings play a leading role in strategic growth of the National Reserve System in Australia, and provide a critical stimulus fornon-government investment. Unprecedented expansion of the National Reserve System followed an historic boost in Australian Government funding under Caring for Our Country 2008–2013. This expansion was highly economical for the Australian Government, costing an average of only $44.40 per hectare to buy and protect land forever. State governments have contributed about six times this amount toward the expansion of the National Reserve System, after including in-perpetuity protected area management costs. The growth of Indigenous Protected Areas by the Australian Government has cost ~$26 per hectare on average, including management costs capitalised in-perpetuity, while also delivering Indigenous social and economic outcomes. The aggregate annual investment by all Australian governments has been ~$72.6 million per year on protected area growth and ~$1.21 billion per year on recurrent management costs. For the first time in almost two decades, however, the Australian Government’s National Reserve System Program, comprising a specialist administrative unit and funding allocation, was terminated in late 2012. This program was fundamental in driving significant strategic growth in Australia’s protected area estate. It is highly unlikely that Australia can achieve its long-standing commitments to an ecologically representative National Reserve System, and prevent major biodiversity loss, without this dedicated funding pool. The Australian Government has budgeted ~$400 million per year over the next five years (2013-2018) under the National Landcare and related programs. This funding program should give high priority to delivery of national protected area commitments by providing a distinct National Reserve System funding allocation. Under the Convention on Biological Diversity (CBD), Australia has committed to bringing at least 17 percent of terrestrial and at least 10 per cent of marine areas into ecologically representative, well-connected systems of protected areas by 2020 (Aichi Target 11).BIODIVERSITY CONSERVATIONAustralia also has an agreed intergovernmental Strategy for developing a comprehensive, adequate and representative National Reserve System on land andsea that, if implemented, would deliver on this CBD target. Due to dramatic recent growth, the National Reserve System covers 16.5 per cent of Australia’s land area, with highly protected areas, such as national parks, covering 8.3 per cent. The marine National Reserve System extends over one-third of Australian waters with highly protected areas such as marine national parks, no-take or green zones covering 13.5 per cent. Growth has been uneven however, and the National Reserve System is still far from meeting Aichi Target 11, which requires that it also be ecologically representative and well-connected. On land, 1,655 of 5,815 ecosystems and habitats for 138 of 1,613 threatened species remain unprotected. Nonetheless, 436 terrestrial ecosystems and 176 threatened terrestrial species attained minimum standards of protection due to growth of the National Reserve System on land between 2002 and 2012. The gap for ecosystem protection on land – the area needed to bring all ecosystems to the minimum standard of protection – closed by a very substantial 20 million hectares (from 77 down to 57 million hectares) between 2002 and 2012, not including threatened species protection gaps. Threatened species attaining a minimum standard for habitat protection increased from 27 per cent to 38 per cent over the decade 2002–2012. A low proportion of critically endangered species meeting the standard (29 per cent) and the high proportion with no protection at all (20 per cent) are cause for concern, but one which should be relatively easy to amend, as the distributions of these species tend to be small and localised. Protected area connectivity has increased modestly for terrestrial protected areas in terms of the median distance between neighbouring protected areas, but this progress has been undermined by increasing land use intensity in landscapes between protected areas.A comprehensive, adequate and representative marine reserve system, which meetsa standard of 15 per cent of each of 2,420 marine ecosystems and 30 per cent of thehabitats of each of 177 marine species of national environmental significance, wouldrequire expansion of marine national parks, no-take or green zones up to nearly 30per cent of state and Australian waters, not substantially different in overall extentfrom that of the current marine reserve system, but different in configuration.Protection of climate change refugia, connectivity and special places for biodiversityis still low and requires high priority attention. FINANCING TO FILL GAPS AND MEET COMMITMENTSIf the ‘comprehensiveness’ and ‘representativeness’ targets in the agreed terrestrial National Reserve System Strategy were met by 2020, Australia would be likely to have met the ‘ecologically representative’ requirement of Aichi Target 11. This would requireexpanding the terrestrial reserve system by at least 25 million hectares. Considering that the terrestrial ecosystem protection gap has closed by 20 million hectares over the past decade, this required expansion would be feasible with a major boost in investment and focus on long-standing priorities. A realistic mix of purchases, Indigenous Protected Areas and private land covenants would require an Australian Government National Reserve System investment of ~$170 million per year over the five years to 2020, representing ~42 per cent of the $400 million per year which the Australian Government has budgeted for landcare and conservation over the next five years. State, territory and local governments, private and Indigenous partners wouldlikewise need to boost financial commitments to both expand and maintain newprotected areas to meet the agreed National Reserve System strategic objectives.The total cost of Australia achieving a comprehensive, adequate and representativemarine reserve system that would satisfy Aichi Target 11 is an estimated $247 million.