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

Keywords: Aboriginal and Torres Strait Islander, Code of Conduct, Code of Ethics, First Peoples, health practitioners, cultural safety, racism, organisational culture.

Against the backdrop of entrenched poor health outcomes for Aboriginal and Torres Strait Islander peoples, the Australian health professional regulator Ahpra recently released a set of new cultural safety objectives.¹ Australia’s First Peoples, the Aboriginal and Torres Strait Islander Peoples, are the longest living culture in the world. Australia’s healthcare system is one of the best in the world; however, in Australia, the life expectancy of Aboriginal and Torres Strait Islander peoples remains more than 8 years less than the non-Indigenous population. Despite ‘Close the Gap’ efforts,^2,3 chronic diseases remain over-represented in First Peoples. Globally, First Peoples carry the greatest burden of cancer, which partially contributes to the higher mortality rates observed.⁴ Australian studies confirm that First Peoples with the same characteristics as non-Indigenous patients are around one-third less likely to receive appropriate medical care across all conditions, often with fatal consequences. In addition to physical harm, psychological and other indirect harms are experienced through poor access, differential funding, poor communication and generally lower levels of care.^5–9 Jennings et al.¹⁰ reported nearly one-third of respondents had experienced ‘racism in health settings, the majority by communication’, which they described as ‘exclusion, hearing racist names and comments based on stereotypes’.

The poor health and social outcomes for First Peoples is exacerbated by low numbers of First Peoples health professionals. Low levels of attraction and retention of First Peoples health practitioners across most registered health professions persist,^2,3,11 representing only 1% of all registered health practitioners.¹² The reasons for this under-representation are multiple and complex, but critical factors preventing First Peoples from pursuing or persisting with careers in health include racism, peer insensitivity to cultural issues, discrimination, family commitments, poor educational preparation, lack of resources, low expectations and poor preparedness of educators to give effective advice to students hoping to pursue a career in health.^2,13,14 In a recent survey of Australian midwives, Fleming et al. (p. 555) noted ‘over 70% of participants agreed that racism existed in their workplace and that not all staff were respectful to First Peoples midwifery students and staff’.¹⁵ Best¹⁶ further notes that improvements in First Peoples health are strongly linked to increased numbers of Indigenous people working in health service delivery, hence, this under-representation is particularly concerning as it links First Peoples poor health outcomes to employment outcomes. Perhaps most distressing is the loss of First People’s knowledge and wisdom to a system that acutely needs these critical insights for the benefit of all.

At the core of these unacceptable employment and health outcomes are unresolved issues flowing from the intergenerational impacts of colonisation and institutionalised racism generally, and particularly in health care. Bond¹⁷ explains, ‘race was the foundation on which this nation was built, and it continues to structure our society, its institutions and social life’. Institutional racism, described by Mayes¹⁸ as ‘the ways that race has been encoded into medical education, funding regimes, health policy and clinical settings’, permeates the values, beliefs, principles, policies, procedures and workplace cultures of many health organisations, structures, institutions and systems resulting in significant health inequities described above.

Making meaningful change in health care has been slow and difficult; however, registered health practitioners, Indigenous and non-Indigenous, are in a privileged position to drive such cultural change individually at the bedside, but also through influencing the institutions they work within. With one in 17 people employed in Australia being registered health practitioners,¹² this group of Australians has a unique and powerful opportunity to make immediate, significant and positive impact to improve care and health outcomes for Australia’s First Peoples.

The National Registration and Accreditation Scheme (NRAS) administered by the Australian Health Practitioner Regulation Agency (Ahpra) regulates more than 800 000 health practitioners and over 150 000 registered students across 16 health professions. It also accredits more than 740 approved health education programs delivered by over 330 education providers.¹² In June 2018, the 15¹ national health practitioner boards, with the support of Ahpra, accreditation authorities and Aboriginal and Torres Strait Islander health sector leaders, launched a statement of intent.¹⁹ This group committed to use their leadership and influence to achieve equity in health outcomes by 2031 using the NRAS scheme to increase the numbers of First Peoples health professionals and to ensure a culturally safe health workforce supported by nationally consistent standards, codes and guidelines across all professions in the National Scheme.

Ahpra’s Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy states, ‘We share a commitment to ensuring that Aboriginal and Torres Strait Islander Peoples have access to health services that are culturally safe and free from racism so that they can enjoy a healthy life, equal to that of other Australians, enriched by a strong living culture, dignity and justice’.¹⁹ This strategy also outlined the vision that: ‘Patient safety for Aboriginal and Torres Strait Islander Peoples is the norm. We recognise that patient safety includes the inextricably linked elements of clinical and cultural safety, and that this link must be defined by Aboriginal and Torres Strait Islander Peoples’.¹⁹

Codes of Conduct and Codes of Ethics are integral to achieving this vision as, in addition to setting meaningful standards for practitioners, they also make a public declaration of the standards, principles and obligations of the professions that inform the community of the standard of care that can be expected. Codes of Conduct are produced by relevant Boards under the NRAS scheme, whereas Codes of Ethics are published by each profession’s peak body to convey the values and aspirations of the profession. Together, each complements the other setting practice standards that convey the integrity of the profession. Their combined contents are integral to achieving culturally safe practice as the norm, which further positively impacts the recruitment and retention of First Peoples health professionals.

Each of the 16 Ahpra registered practitioners’ (there are now 16 registered health professions, with Nursing and Midwifery now considered as distinct professions from 2020) Codes of Conduct, published by the relevant Board, was analysed for content and assessed against the criteria outlined in Ahpra’s Aboriginal and Torres Strait Islander Health Strategy – Strategic Plan,¹ which states:

To ensure culturally safe and respectful practice, health practitioners must:

1. Acknowledge colonisation and systemic racism, social, cultural, behavioural and economic factors that impact individual and community health;

2. Acknowledge and address individual racism, their own biases, assumptions, stereotypes and prejudices and provide care that is holistic, free of bias and racism;

3. Recognise the importance of self-determined decision-making, partnership and collaboration in health care, which is driven by the individual, family and community; and

4. Foster a safe working environment through leadership to support the rights and dignity of Aboriginal and Torres Strait Islander people and colleagues (p. 9).¹

Similarly, the contents of each profession’s peak professional body Code of Ethics, accessible through each profession’s public website, was analysed against the same criteria outlined above. This assessment was undertaken primarily by one author with additional discussion and analysis from the research team.

Table 1 compares the content of each professions Code of Conduct and Code of Ethics regarding guidance on Aboriginal and Torres Strait Islander Health and Cultural Safety, and alignment with Ahpra cultural safety criteria.^1,20–54

Table 1.  Comparison of Aboriginal and Torres Strait Islander Health and Cultural Safety content in Code of Conduct and Code of Ethics for 16 Ahpra registered health professions
ATSI, Aboriginal and Torres Strait Islander; CALD, culturally and linguistically diverse

Three of the 16 registered health professions (Aboriginal and Torres Strait Islander Health Practitioners, Nursing, and Midwifery) Codes of Conduct explicitly acknowledged the requirement for culturally safe practice as it applies to First Peoples. Nursing and Midwifery Codes reflected all four criteria listed by Ahpra for cultural safety in their codes and were the only Codes of Conduct that identified the objective of ‘healthcare free of racism’. The Aboriginal and Torres Strait Islander Practitioners Code partially met the criteria. The remaining 13 professions’ Codes of Conduct made general reference to ‘culturally safe and sensitive practice’, assimilating First Peoples and Culturally and Linguistically Diverse (CALD) people.

Two of the 16 registered professions’ peak body Codes of Ethics (Pharmacy and Psychology) articulated specific ethical responsibilities to First Peoples. Although the Australian Physiotherapy Association (APA) published an additional (non-Board) Code of Conduct, the contents of this document reflected the values and principles commonly associated with Codes of Ethics, hence, it was included in the analysis on that basis. The APA Code of Conduct did not reflect Ahpra’s cultural safety criteria; however, APA have also published an innovate reconciliation action plan (RAP). This comprehensive document provides guidance to physiotherapists that meets all four Ahpra criteria. Of the remaining 13, eight (Nursing, Midwifery, Medicine, Dentistry, Occupational Therapy, Medical Radiation Practitioners, Chiropractors, and Chinese Medicine) promoted valuing diversity and respect for culture in general terms. The final five had no publicly accessible Code of Ethics (Paramedicine, Optometry, Podiatry, Osteopathy, and Aboriginal and Torres Strait Islander Health Practitioners).

Although the Australian College of Nursing (ACN) had robust and clear guidance regarding appropriate culturally safe care in its 2008 Code of Ethics, the recent shift to adopt the International College of Nursing Code (ICN) has undermined the strength of cultural safety to the profession. Similarly, Australian Midwives have adopted the International Confederation of Midwives Code of Ethics, which makes generic statements about empowering women within their culture/society. The Australian Psychological Society (APS) has a comprehensive set of ethical guidelines for practitioners working with First Peoples clients, which incorporate the four criteria listed by Ahpra; however, this is not publicly accessible, limiting its use as a visible model of professional commitment generally and, in particular, limiting its use in communicating the profession’s values and commitments for clients and other health practitioners.

The term ‘cultural safety’ was originally conceptualised by Irihapeti Ramsden through her work with Māori nurses in New Zealand. She described cultural safety as a framework that could help people in nursing education, teachers and students ‘become aware of their social conditioning and how it has effected them and therefore their practice’⁵⁵ (p. 111). With this awareness, Ramsden argued that the negative impacts of colonisation on Indigenous peoples, such as widespread damaging attitudes and beliefs could be challenged, and the ongoing impact of historical, social and political processes that had created significant health and social disparities for Māori people could be overcome. She further believed that such change could positively impact the attraction and retention of Māori nurses.

‘Cultural safety’ is now widely recognised in Australia, noting key differences that acknowledge the cultural diversity of Aboriginal and Torres Strait Islander populations throughout Australia. Philips further developed understanding of cultural safety in the Australian context outlining three requirements for cultural safety being: (1) knowledge of and respect for self; (2) knowledge of and respect for Aboriginal and Torres strait Islander people; and (3) commitment to decolonising the healthcare system.⁵⁶

Building on the work of Philips,⁵⁶ Ahpra’s Cultural Safety Strategy Group developed and adopted the following definition:

‘Cultural safety is determined by Aboriginal and Torres Strait Islander individuals, families and communities. Culturally safe practise is the ongoing critical reflection of health practitioner knowledge, skills, attitudes, practising behaviours and power differentials in delivering safe, accessible and responsive healthcare free of racism’.

The four ‘how to’ points, which formed the basis of this analysis, outlined previously, now provide the roadmap for promoting cultural safety across the registered health professions. A key strategy to drive practice change is to embed these requirements into health practitioner Codes of Conduct and Codes of Ethics. The analysis undertaken here provides a baseline that identifies the gaps, thus highlighting opportunities to strengthen practice standards with respect to cultural safety through review and updating of all Codes.

Codes of Conduct outline the professional norms of practice internally within the profession. Codes of Ethics traditionally communicate the virtues, values and principles of the profession internally within the profession, and externally to the public.⁵⁷ Together, these key documents communicate to the public what standard of care they should expect. For many health practitioners, explicit consideration of cultural safety may be an aspect of practice they have not previously been challenged to consider. Hence, the explicit embedding of cultural safety in the Codes opens a portal requiring deeper engagement. Although mere compliance with a Code may be regarded as a superficial form of engagement, it can be a critical first step in engaging professionals who may otherwise not have considered the impact of their own cultural assumptions and biases on the health outcomes for First Peoples. Importantly, Codes also play a role in regulation with practitioner conduct and professionalism being assessed against the norms outlined in each Code of Conduct. Hence, the active inclusion of cultural competency, and requirement to deliver culturally safe care as a practice standard, opens a door for regulatory action should practitioners fall short in this area of practice.

The absence of a publicly accessible Code of Ethics for 5 of the 16 registered health professions (Paramedicine, Optometry, Podiatry, Osteopathy, and Aboriginal and Torres Strait Islander Health Practitioners) reveals a gap that warrants further work by those professions. Interestingly, all Codes are set in the sole context of a practitioner treating patients, and limited guidance is offered regarding each practitioner’s role in creating a culturally safe workplace in peer-to-peer interactions, or in creating culturally safe practices and policies. The addition of these broader considerations including the experience of Indigenous health practitioners could further strengthen the Codes.

Because Codes shape and drive the systems, practices and policies that determine healthcare standards in Australia, they are a critical part of the infrastructure of change if institutional racism is to be eliminated in health care. While Laverty et al.⁵⁸ (p. 16) were referring to health safety and quality standards when they stated, ‘Cultural safety requires embedding in not only course accreditation for each health profession — including measures to reduce resistance — but also in the standards governing clinical professionalism and quality’; the same observation must apply to the standards governing the professionalism of health practitioners through each profession’s Code of Conduct and Code of Ethics.

A key finding from this analysis was the conflation in the Codes of First Peoples in Australia with other CALD groups. As noted in Table 1, most Codes combined First Peoples with those from CALD backgrounds making the common statement that practitioners must show ‘respect for and sensitivity towards the cultural needs’. This joining together undermines the unique and special place of Australia’s First Peoples as the sovereign owners of this country.

Sovereignty refers to legal and political power and a supreme authority to govern.^59,60 From one standpoint, First People’s sovereignty refers to the rights inherent in, and emanating from, being First Peoples of this country and living according to laws established within that. From another standpoint, sovereignty pertains to human rights and self-determination actualised in the right to determine one’s own life and destiny (as opposed to having these determined by governments, laws and political agendas). In Australia, First Peoples hold this unique place, a place that is not shared with those from CALD backgrounds. Hence, recognition of sovereignty is a critical first step to demonstrating respect for cultural safety in Aboriginal and Torres Strait Islander Health. Institutional racism in Australian health care cannot be addressed without attending to the denial of Indigenous sovereignty and control of land, lives and futures. Medical anthropologist, Phillips,⁵⁶ calls for ‘new terms of reference in Indigenous health which centre Indigenous sovereignty’ rather than ‘inclusion and equity discourse’ that merely recentres whiteness.

If cultural safety is to become the norm for First Peoples, acknowledgement of the unique status as sovereign, traditional custodians of this land must be re-enforced in professional codes, identifying another area of future reform. It requires ongoing reflection of health practitioner knowledge, skills, attitudes and behaviours that recognise the power differentials at play when delivering safe, accessible and responsive health care free of racism. As articulated in Ahpra’s Cultural Safety Strategy,¹ achieving cultural safety in health care will require the acknowledgment of systemic racism, social, cultural, behavioural and economic factors that impact individual and community.

An analysis of this kind has not previously been undertaken; hence, this paper adds an important and comprehensive snapshot of the current situation. Of the 16 Ahpra-registered health practitioner Board Codes of Conduct analysed, three (Nursing, Midwifery and Aboriginal and Torres Strait Islander Health practitioners) outlined specific obligations to First Peoples. The remaining 13 framed obligations in general terms of ‘culturally safe and sensitive practice’, assimilating Aboriginal and Torres Strait Islander peoples and CALD people, failing to respect the unique sovereign place of First Peoples in Australia.

Two Codes of Ethics (Pharmacy and Psychology) articulated specific ethical responsibilities to First Peoples. Although not articulating cultural safety in the APA (Physiotherapy) Code of Conduct, all Ahpra cultural safety criteria were met in the APA reconciliation action plan.⁴⁹ Of the remaining 13 Codes, eight (Nursing, Midwifery, Medicine, Dentistry, Occupational Therapy, Medical Radiation Practitioners, Chiropractors, and Chinese Medicine) made generic statements about respect for culture. Five had no publicly accessible Code of Ethics (Paramedicine, Optometry, Podiatry, Osteopathy, and Aboriginal and Torres Strait Islander health practitioners).

Health profession Codes of Conduct and Codes of Ethics form a critical foundation from which to communicate standards of care; hence, they have a central role in driving the required system and standards changes to achieve culturally safe health care. This review has shown that, currently, their contents could be improved to understand and address the systemic racism in health care. There is also scope to improve guidance for practitioners to overcome their own biases, to understand the impacts of institutional racism in the healthcare system, and to understand the critical role of recognising the sovereignty of Indigenous Australians in improving health outcomes.

As all 16 health practitioner board Codes of Conduct fall under the auspices of NRAS, the gaps identified in this analysis provide a clear roadmap to create nationally consistent and strengthened frameworks with respect to cultural safety for First Peoples as a core professional competency. Each health professional peak body is also invited to review the contents of their own Codes of Ethics to include explicit recognition of First Peoples sovereignty, acknowledgement of the ongoing harms of colonisation and institutional racism. The non-negotiable requirement to listen and respond to the voices, wisdom and needs of First Peoples as partners in their own health are the necessary precursors for increasing the number of First Peoples health professionals. Without these steps, the vision of closing the gap in First Peoples health outcomes remains vulnerable. Together, Codes of Conduct and Codes of Ethics can form part of the necessary foundation to achieve culturally safe care, systems and workplaces where the rights and dignity of First Peoples is respected as the indisputable norm.

The authors declare no competing interests.