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

Abstract

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. MethodsFollowing 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. ResultsMost 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. ConclusionsThe 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.

Using document analysis to revise competency frameworks: Perspectives from the revision of competency standards for dietitians

“…Ensuring competency standards reflect the performance required of the profession is a key step to advancing practice that is culturally safe and responsive. In addition, Codes of Conduct and Codes of Ethics are key drivers of practice and reform ( 20 ). There have been calls to update all Codes of Conduct and Codes of Ethics to ensure cultural safety specifically relating to Aboriginal and Torres Strait Islander peoples is included ( 20 ).…”

Are cultural safety definitions culturally safe? A review of 42 cultural safety definitions in an Australian cultural concept soup

“…All de nitions (except the APHRA de nition) occur without being re exive to cultural diversity, power, and identity. The individual authors of organisational de nitions (Table 1) are unknown, in that they do not identify themselves or their cultures, and in doing so demonstrate 'redundant re exivity' (n=28; Table 1, Rows 4,5,6,7,8,10,11,12,13,15,16,17,18,19,20,22,24,25,27,28,32,34,35,36,37,38,40,and 42).…”

“…Almost half of the de nitions (n=20, Table1, Rows 4, 5, 6, 8, 9, 10,12, 13, 16, 18, 29, 31, 32, 33, 34, 35, 36, 37, 38, and 39) have unknown provenance. There are nine de nitions (Table1,Rows 21,22,24,25, 28,34,39,41,and 42…”

“…Rows 4, 5, 10, 11, 12, 13,17,19,20,21,22,24,25,27, 28,32,34,35, 36,37, 38, 40, and 42) with western colonial hierarchical governance structures that are at odds with First Nations community governance practices (Panaretto, Wenitong et al, 2014). There are some non-government organisations based on First Nations professional interests and advocacy (n=3; Table 1, Rows 7, 10, and 16), but where governance structures are still hierarchical based in colonial models.…”

Marŋgithirri guŋga’yunarawu ga guŋga’yunyarawu marŋgithinyarawu Learning to connect and connecting to learn: Preparing the rural and remote allied health workforce through a co‐created student‐implemented service in East Arnhem, Australia

“…4 Clinical placements in remote Aboriginal communities can be a challenge for students particularly for those who have never lived, worked or had social connections with an Aboriginal or Torres Strait Islander community. 12 While culturally safe practice 4 and Indigenous knowledges 13 are increasingly embedded in allied health curriculum and professional body requirements, 14,15 how students learn culturally safe and responsive practice in a real-world setting within student-implemented services needs further exploration. 16 The aim of this study was to explore the process of learning for allied health students providing a co-created, student-implemented allied health service for older Yolŋu in remote East Arnhem, Australia, from the perspectives…”