Evaluating awareness of Cultural Safety in the Australian midwifery workforce: A snapshot

Predictors of cultural competence among healthcare professional in maternity department: A systematic review

BACKGROUND

In recent years, the number of foreign women seeking perinatal care from health services has increased. These women come from diverse cultural and social backgrounds, highlighting the importance of properly training healthcare professionals to respond effectively to their needs. Cultural Competence refers to the set of skills, knowledge, and awareness that providers must possess to deliver care to patients from different cultures.

AIM

This study aims to investigate the determinants of Cultural Competence in healthcare professionals who assist women during childbirth.

METHOD

A systematic literature review was conducted using MEDLINE/PubMed, Web of Science, CINAHL, Scopus, and ProQuest. Quantitative studies were included if they investigated at least one psychosocial characteristic in midwives or staff assisting pregnant women.

FINDINGS

Out of 4,193 articles, 8 were selected that measured the level of Cultural Competence using validated scales. These studies related the data to the sociodemographic characteristics of the chosen population. Variables significantly associated with Cultural Competence that recurred in at least two studies were selected: age, gender, years of experience, role, and previous Cultural Competence training. These determinants were categorized as (a) individual variables and (b) Jobs-related variables.

DISCUSSION

Age diversity boosts Cultural Competence (CC) in healthcare teams, enhancing care for diverse women. Our study confirms prior cultural training and experience with different cultures predict CC. Health services should promote CC, but understanding in high-income countries remains limited.

CONCLUSIONS

By strategically promoting age diversity, facilitating cultural training, and encouraging experiences with diverse populations, healthcare institutions can significantly improve the Cultural Competence of their staff.

How do midwives learn about, understand, and integrate Cultural Safety into their care of First Nations women and families? A qualitative exploration

PROBLEM

Midwives are required to provide care based on Cultural Safety for First Nations women and families. Recent literature has suggested that midwives' understanding of Cultural Safety and how it translates into their practice differs widely. This disparity requires further exploration.

BACKGROUND

The Australian professional midwifery codes and standards state that there is a requirement to provide care based on Cultural Safety. It is critical to understand how First Nations people's history and culture impacts their health and wellbeing, requiring midwives to recognise how this may impact care.

AIM

To determine Australian midwives' knowledge and understanding of Cultural Safety and how this translates into their practice when caring for First Nations women and families.

METHODS

A qualitative study was undertaken. Data were collected via semi-structured interviews with 12 midwives practicing in Australia. Data were transcribed and thematically analysed.

FINDINGS

Three themes were identified: 'Society and Systems', 'Knowingness versus Understanding', and 'Personal Qualities, Engagement and Partnerships' which highlight the strengths and deficits of Cultural Safety education and its integration into midwifery practice in Australia.

DISCUSSION

Health systems providing maternity care remain rooted in Western biomedical philosophies, which influences the practice of Cultural Safety at all levels. Midwives are beginning to understand the ongoing impact of colonisation on the health and wellbeing of First Nations families, but still face challenges when striving to provide culturally safe care.

CONCLUSION

Cultural Safety must be valued at an organisational level, in which midwives can engage in authentic, maternity-based educational programs led by suitably prepared educators.

'God is the one who give child': An abductive analysis of barriers to postnatal care using the Health Equity Implementation Framework

Background

Postnatal care is recommended as a means of preventing maternal mortality during the postpartum period, but many women in low- and middle-income countries (LMICs) do not access care during this period. We set out to examine sociocultural preferences that have been portrayed as barriers to care.

Methods

We performed an abductive analysis of 63 semi-structured interviews with women who had recently given birth in three regions of Ethiopia using the Health Equity Implementation Framework (HEIF) and an inductive-deductive codebook to understand why women in Ethiopia do not use recommended postnatal care.

Results

We found that, in many cases, health providers do not consider women's cultural safety a primary need, but rather as a barrier to care. However, women's perceived refusal to participate in postnatal visits was, for many, an expression of agency and asserting their needs for cultural safety.

Trial registration

n/a.

Conclusions

We propose adding cultural safety to HEIF as a process outcome, so that implementers consider cultural needs in a dynamic manner that does not ask patients to choose between meeting their cultural needs and receiving necessary health care during the postnatal period.

Patient-Defined Cultural Safety in Perinatal Interventions: A Qualitative Scoping Review

Problem

Cultural safety is an approach to patient care designed to facilitate respect of patients' cultural needs and address inequities in care in culturally diverse situations.

Background

Much literature considers culturally safe care during the perinatal period, yet little is known about how patients experience and understand cultural safety. This is despite patient-defined care being one of the definitions of cultural safety.

Question Hypothesis or Aim

This scoping review investigates what is known from existing qualitative literature about patients' experience of cultural safety frameworks in perinatal interventions.

Methods

A search for "cultural safety" OR "culturally safe" in PubMed, Ovid Medline, Ovid Embase, Cumulated Index to Nursing and Allied Health Literature, Scopus, Scielo, and Latin America and the Caribbean Literature on Health Sciences returned 2233 results after deduplication. Title-abstract and full-text screenings were conducted to identify qualitative studies of cultural safety from perinatal patients' perspectives. Seven studies were included in the final analysis. Data were open coded using NVivo.

Findings

Three themes were identified: (1) care that acknowledged that their lives were different from patients in the dominant culture, (2) receiving care in community, and (3) care providers who respected their choices and culturally specific knowledge.

Discussion

This research shows how cultural safety intersects with other equity-based frameworks used in midwifery and obstetrics.

Conclusion

Building on this research could lead to new protocols that address complex social and physical needs of marginalized people during the perinatal period.

Audit tools for culturally safe and responsive healthcare practices with Aboriginal and Torres Strait Islander people: a scoping review

Aboriginal and Torres Strait Islander people in Australia face disparities in accessing culturally safe and appropriate health services. While current cultural safety and responsiveness frameworks set standards for improving healthcare practices, ensuring accountability and sustainability of changes, necessitates robust mechanisms for auditing and monitoring progress. This study examined existing cultural safety audit tools, and facilitators and barriers to implementation, in the context of providing culturally safe and responsive healthcare services with Aboriginal and Torres Strait Islander people. This will assist organisations, interested in developing tools, to assess culturally responsive practice. A scoping review was undertaken using Medline, Scopus, CINAHL, Informit and PsychInfo databases. Articles were included if they described an audit tool used for healthcare practices with Aboriginal and Torres Strait Islander people. Selected tools were evaluated based on alignment with the six capabilities of the Indigenous Allied Health Australia (IAHA) Cultural Responsiveness in Action Framework. Implementation barriers and facilitators were identified. 15 papers were included. Audit tools varied in length, terminology, domains assessed and whether they had been validated or evaluated. Seven papers reported strong reliability and validity of the tools, and one reported tool evaluation. Implementation facilitators included: tool comprehensiveness and structure; effective communication; clear organisational responsibility for implementation; commitment to prioritising cultural competence; and established accountability mechanisms. Barriers included: the tool being time-consuming and inflexible; responsibility for implementation falling on a small team or single staff member; deprioritising tool use; and lack of accountability for implementation. Two of the six IAHA capabilities (respect for the centrality of cultures and inclusive engagement) were strongly reflected in the tools. The limited tool evaluation highlights the need for further research to determine implementation effectiveness and sustainability. Action-oriented tools, which comprehensively reflect all cultural responsiveness capabilities, are lacking and further research is needed to progress meaningful change within the healthcare system.

Translating Cultural Safety to the UK

Disproportional morbidity and mortality experienced by ethnic minorities in the UK have been highlighted by the COVID-19 pandemic. The 'Black Lives Matter' movement has exposed structural racism's contribution to these health inequities. 'Cultural Safety', an antiracist, decolonising and educational innovation originating in New Zealand, has been adopted in Australia. Cultural Safety aims to dismantle barriers faced by colonised Indigenous peoples in mainstream healthcare by addressing systemic racism.This paper explores what it means to be 'culturally safe'. The ways in which New Zealand and Australia are incorporating Cultural Safety into educating healthcare professionals and in day-to-day practice in medicine are highlighted. We consider the 'nuts and bolts' of translating Cultural Safety into the UK to reduce racism within healthcare. Listening to the voices of black, Asian and minority ethnic National Health Service (NHS) consumers, education in reflexivity, both personal and organisational within the NHS are key. By listening to Indigenous colonised peoples, the ex-Empire may find solutions to health inequity. A decolonising feedback loop is required; however, we should take care not to culturally appropriate this valuable reverse innovation.

How is cultural safety understood and translated into midwifery practice? A scoping review and thematic analysis

AIM

To identify and understand the scope of the literature published since January 2008 that explored Australian midwives understanding of cultural safety and how this is translated into their practice when caring for First Nations women and families.

BACKGROUND

Recognition and understanding of First Nations peoples history and culture and the impact this has on the health and wellbeing of women and their families is essential if the midwife is to promote culturally safe and respectful maternity care. The role and responsibilities of the midwife in ensuring that their practice is culturally safe are now reflected in the Australian professional midwifery codes and standards. Whilst midwifery academics' awareness of cultural safety and how it is taught within midwifery education programs have previously been explored, at present, little is known about midwives' understanding of cultural safety, and how this translates into their clinical practice.

METHODS

A Scoping Review was undertaken following Arksey and O'Malley's five step process. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses - Scoping Review extension checklist. Twelve studies met the criteria for inclusion. Thematic analysis was used to analyse the data and organise the results.

RESULTS

Thematic analysis, guided by two predetermined review questions led to the identification of six overarching themes: 'Awareness of deficiencies', 'The importance of meeting women's diverse needs', 'Understanding relationships as a foundation for culturally safe care', 'Working in partnership with others', 'Providing individualised care' and 'Fostering effective relationships and communication'. One sub-theme of the first theme was identified, this was named 'Seeking an understanding of culture'.

CONCLUSION

Australian midwives' level of understanding of cultural safety and how it is translated into their midwifery practice when caring for First Nations women and their families differ widely. Midwives across Australia require increased and equitable access to appropriate opportunities to improve their knowledge and understanding of cultural safety. Whilst theoretical learning on cultural safety has a place in all midwives annual mandatory training requirements, this should ideally be supplemented, where possible, with opportunities for immersive practice in communities. Immersion was considered the optimal way to gain rich knowledge and understanding to strengthen culturally safe midwifery practice. Continuity models of midwifery care which incorporate the principles of cultural safety should be consistently implemented across Australia. These models enable midwives, women, families, communities, and Aboriginal Support Workers to work in collaboration towards achieving optimal outcomes for mothers and babies.

STUDY REGISTRATION

N/A.

There is no health without cultural safety: Why cultural safety matters

The authors would like to pay respect to Aboriginal and Torres Strait Islander Peoples by acknowledging the traditional owners of the lands on which this paper was written, the Wadjuk people of the Nyungar Nation and the Darkinjung people. One author (XX) would like to acknowledge her Wiradjuri ancestry and express respect to her Elders past and present and to Culture and Country.

Aboriginal and Torres Strait Islander Subjects in a Graduate Diploma of Midwifery: A pilot study

Background: Australian Nursing and Midwifery Accreditation Council prescribes midwifery accreditation standards that support students' development in Aboriginal and Torres Strait Islander Health and cultural safety to be deemed practice ready. However, the impact of training programmes are not widely explored.Aim: This study aimed to assess the impact of a mandatory 8-week online subject focussed on the development of culturally safe practices among midwifery students.Methods: The Ganngaleh nga Yagaleh cultural safety assessment tool was used to collect online quantitative data from post graduate midwifery students at the commencement and completion of an online subject.Results: Through a purposive sample (n = 10) participant perceptions of culturally safe practices remained relatively unchanged, except for three items of the Ganngaleh nga Yagaleh cultural safety assessment tool.Discussion: Findings demonstrate that when post graduate midwifery students are exposed to Aboriginal and Torres Strait Islander perspectives of Australia's colonial history it impacts their sense of optimism, personal values and beliefs about the healthcare they will provide to Aboriginal and Torres Strait Islander peoples. However, midwifery students who self-identified as Aboriginal and/or Torres Strait Islander people, reported a decline in optimism when imagining a healthcare system free of racism.Conclusion: The subject did not impact on cultural safety scores. This may be due to prior learning of student midwives. Educators should consider building on prior knowledge in post graduate midwifery to ensure the content is contextualised to midwifery.

Achieving cultural safety for Australia's First Peoples: a review of the Australian Health Practitioner Regulation Agency-registered health practitioners' Codes of Conduct and Codes of Ethics

Objective Health practitioners' Codes of Conduct and Codes of Ethics articulate practice standards across multiple domains, including the domain of cultural safety. As key tools driving individual practice and systems reform, Codes are integral to improving health outcomes for Aboriginal and Torres Strait Islander peoples. It is, therefore, critical that their contents specify meaningful cultural safety standards as the norm for institutional and individual practice. This research assessed all Codes for cultural safety specific content. Methods Following the release of the Australian Health Practitioner Regulation Agency's (Ahpra) Health and Cultural Safety strategy 2020-25, the 16 Ahpra registered health practitioner Board Codes of Conduct and professional Codes of Ethics were analysed by comparing content to Ahpra's new cultural safety objectives. Two Codes of Conduct, Nursing and Midwifery, met these objectives. The Aboriginal and Torres Strait Islander Health Practitioners Code partially met these objectives. Results Most Codes of Conduct (14 of 16) conflated Aboriginal and Torres Strait Islander peoples with culturally and linguistically diverse (CALD) communities undermining the sovereignty of Australia's First Peoples. Eleven professions had a Code of Ethics, including the Physiotherapy Code of Conduct, which outlined the values and ethical principles of practice commonly associated with a Code of Ethics. Of the 11 professions with a Code of Ethics, two (Pharmacy and Psychology) articulated specific ethical responsibilities to First Peoples. Physiotherapy separately outlined cultural safety obligations through their reconciliation action plan (RAP), meeting all Ahpra cultural safety objectives. The remaining eight advocated respect of culture generally rather than respect for Aboriginal and Torres Strait Islander cultures specifically. Conclusions The review identified multiple areas to improve the codes for cultural safety content for registered health professions, providing a roadmap for action to strengthen individual and systems practice while setting a clear regulatory standard to ensure culturally safe practice becomes the new norm. It recommends the systematic updating of all professional health practitioner Board Codes of Conduct and professional Codes of Ethics based on the objectives outlined in Ahpra's Cultural Safety Strategy. What is known about the topic? Systemic racism and culturally unsafe work environments contribute to poor health outcomes for Aboriginal and Torres Strait Islander peoples. They also contribute to the under-representation of Aboriginal and Torres Strait Islander peoples in the health workforce, denying the system, and the people who use and work in it, much needed Indigenous knowledge. Creating a culturally safe healthcare system requires all health practitioners to reflect on their own cultural background, to gain appreciation of the positive and negative impacts of individually held cultural assumptions on the delivery of healthcare services. Competence in cultural safety as a required standard of practice is therefore essential if broad, sustainable and systemic cultural change across the health professions and ultimately across Australia's healthcare system is to be achieved. Given that Codes of Conduct and Codes of Ethics are integral in setting the practical and moral standards of the professions, their contents with respect to cultural competence are of great importance. What does this paper add? A review of this type has not been undertaken previously. Following the establishment of the Ahpra Aboriginal and Torres Strait Islander Health Strategy Group, release of Ahpra's 2018 Statement of intent, and the 2019 Aboriginal and Torres Strait Islander Health and Cultural Safety strategic plan and Reconciliation Action Plan, we analysed the content of each of the 16 registered health professions Codes of Conduct and Code of Ethics looking for content and guidance in accordance with the new national cultural safety definition. Several opportunities to improve the Codes of Conduct and Codes of Ethics were identified to realise the vision set out in the statement of intent including through the application of the National Law. This analysis provides a baseline for future improvements and confirms that although some current health practitioner Codes of Conduct and Codes of Ethics have begun the journey of recognising the importance of cultural safety in ensuring good health outcomes for Australia's Indigenous peoples, there is broad scope for change. What are the implications for practitioners? The gaps identified in this analysis provide a roadmap for improvement and inclusion of Aboriginal and Torres Strait Islander Health and cultural safety as a required standard in Codes of Conduct and Codes of Ethics for all registered health practitioners. Although it is recognised that Codes alone may not change hearts and minds, codifying the clinical competency of cultural safety provides a portal, and a requirement, for each individual practitioner to engage meaningfully and take responsibility to improve practice individually and organisationally.

Exploring differences in perceptions of child feeding practices between parents and health care professionals: a qualitative study

BACKGROUND

Evidence on child feeding practice is often based on the perspectives and experiences of parents and less that of health practitioners. In this study, we explored child feeding practice in Aboriginal communities in northern Australia from both the parents and health practitioners' perspectives with the aim of informing nutrition improvement programs.

METHODS

Qualitative research methods were employed. Using semi-structured interviews, parents (n = 30) of children aged 2-5 years, and 29 service providers who were involved in the delivery of child health and nutrition programs in the same communities, were asked about child feeding attitudes and practices. Responses were analyzed through inductive and deductive analysis, recognizing that worldviews influence child feeding practices.

RESULTS

Sharing food was a central practice within families. Parents highly valued development of child independence in food behavior but were conflicted with the easy access to unhealthy food in their communities. This easy access to unhealthy food and inadequate food storage and kitchen facilities for some families were major challenges to achieving optimal diets for children identified by Aboriginal families and service providers. The responsive style of parenting described by parents was often misunderstood by service providers as sub-optimal parenting when viewed through a dominant western lens.

CONCLUSIONS

Approaches to support healthy feeding practices and optimal child nutrition require health-enabling food environments. Along with a community-based Aboriginal health workforce, it is paramount that the non-Aboriginal workforce be supported to be reflective of the impact of worldview on their practice, to ensure a culturally safe environment for families where parenting styles are understood and appropriately supported.