Dissertation – Cultural Competence and Cultural Safety in Australian Healthcare Delivery

Abstract

Cultural safety and cultural competence are central to equitable, high quality care for Aboriginal and Torres Strait Islander peoples and for culturally and linguistically diverse (CALD) communities in Australia. This dissertation extract reports a qualitative-dominant, convergent parallel mixed-methods study of how clinicians in a metropolitan Australian local health district understand and enact these concepts. Semi-structured interviews with 18 clinicians were merged with a cross-sectional survey of 240 clinical staff. Framework analysis produced four themes: cultural safety was frequently conflated with competence; clinicians relied on informal rather than accredited interpreting; training built awareness without changing practice; and systemic barriers constrained individual intent. Survey findings corroborated the qualitative account, with only 38 per cent of respondents routinely engaging accredited interpreters. The study argues that cultural safety, which is defined by the recipient of care, requires organisational and structural reform rather than individual competence alone, consistent with the Cultural Respect Framework and Australia’s national safety and quality standards.

Introduction

Australia is among the most culturally diverse nations in the world. At the 2021 Census more than one fifth of people reported speaking a language other than English at home, and almost half had a parent born overseas (Australian Bureau of Statistics [ABS], 2022). Aboriginal and Torres Strait Islander peoples, the First Peoples of this continent, sustain the oldest continuing cultures in the world and draw on enduring strengths of family, community and connection to Country, strengths that the Aboriginal community-controlled health sector has translated into internationally regarded models of primary care. Persistent inequities in access and outcomes nonetheless remain, and their elimination is a shared national commitment under the National Agreement on Closing the Gap, which places self-determination and genuine partnership at the centre of reform (Australian Government, 2020; Australian Institute of Health and Welfare [AIHW], 2023).

Two related but distinct ideas frame contemporary responses to this diversity. Cultural competence describes the knowledge, attitudes and skills that a clinician brings to cross-cultural encounters. Cultural safety, by contrast, is defined not by the provider but by the person receiving care: an environment is culturally safe only when the patient and their family judge it to be so, and unsafe care includes any act that diminishes a person’s cultural identity (Curtis et al., 2019). Australian regulators have adopted this recipient-defined standard. The Nursing and Midwifery Board of Australia (NMBA, 2018) embeds cultural safety in its Code of conduct for nurses, requiring practitioners to reflect on their own culture, to work in partnership, and to provide care free of racism.

This dissertation extract examines how clinicians in one metropolitan health service understand and enact cultural competence and cultural safety, with particular attention to the care of Aboriginal and Torres Strait Islander patients and patients from CALD backgrounds. It concentrates on three practical domains that recur in the Australian literature: professional training, the use of interpreters, and the systemic conditions that shape everyday care. Three questions guided the study:

1. How do clinicians understand and differentiate cultural competence and cultural safety in their everyday practice?
2. What enablers and barriers shape culturally safe care for Aboriginal and Torres Strait Islander and CALD patients, including interpreter use and training?
3. What organisational and systemic changes do clinicians identify as necessary to move from cultural awareness to culturally safe practice?

Literature Review

From cultural competence to cultural safety

The distinction between competence and safety has become the central conceptual debate in this field. Competence frameworks equip clinicians with knowledge and skills but risk reducing culture to a static checklist of traits attributed to an “other” (Truong et al., 2017). Cultural safety reframes the task in three ways: it turns attention onto the culture, power and assumptions of the clinician and institution rather than the patient; it demands continuing reflexivity rather than a single training event; and it locates the judgement of safety with those who receive care (Curtis et al., 2019). Systematic reviews of competency interventions report improvements in practitioner knowledge and attitudes but far weaker evidence that these translate into changed practice or improved patient outcomes (Clifford et al., 2015; Truong et al., 2017). This gap between awareness and outcome motivates the shift from competence to safety and frames the present study.

Racism and the structural determinants of care

Cultural safety is inseparable from the problem of racism, which is a modifiable determinant of health rather than an unfortunate backdrop. Racism operates interpersonally, through dismissive communication and stereotyping, and institutionally, through routines and policies built around the dominant culture (Paradies, 2016). Australian scholarship argues that improving Aboriginal and Torres Strait Islander health therefore requires services to change, rather than expecting patients to adapt, shifting the focus of intervention from individual deficit to institutional accountability (Durey & Thompson, 2018). This structural reading is important for interpreting clinician accounts, because it predicts that individual goodwill will be insufficient where organisational conditions remain unchanged.

Language access and CALD communities

For CALD patients, language access is the most concrete expression of cultural safety. Effective communication depends on accredited interpreters, yet Australian and international evidence consistently documents their underuse, with clinicians relying instead on family members, bilingual staff or gestured improvisation under time pressure (Komaric et al., 2019; Phillips & Travaglia, 2019). Informal interpreting compromises accuracy, consent and confidentiality, and can transfer inappropriate responsibility onto children or relatives. Provider-reported barriers include the time required to book interpreters, limited availability for particular languages, and low awareness of how to access services, factors that recur across primary and acute care settings (Phillips & Travaglia, 2019).

Policy architecture in Australia

Australian policy has moved cultural safety from aspiration to obligation. The Cultural Respect Framework 2016-2026 commits all health systems to embedding cultural respect in planning, workforce and service delivery (Australian Health Ministers’ Advisory Council [AHMAC], 2016). The National Safety and Quality Health Service Standards tie hospital accreditation to specific actions for Aboriginal and Torres Strait Islander health, including partnership, workforce and anti-racism measures (Australian Commission on Safety and Quality in Health Care [ACSQHC], 2017). The National Scheme’s cultural safety strategy extends the same expectation across all registered health professions and names culturally safe practice as inseparable from patient safety (Australian Health Practitioner Regulation Agency [Ahpra], 2020). Reviews of what actually works, however, emphasise multi-level intervention combining practitioner education with organisational and systemic change, rather than training alone (Bainbridge et al., 2015).

Research gap

Much of the Australian evidence base examines single professions, single patient groups, or training interventions in isolation. Less is known about how a multidisciplinary clinical workforce reconciles the concepts of competence and safety in day-to-day practice, and how that understanding maps onto measurable behaviours such as interpreter use across both Aboriginal and Torres Strait Islander and CALD care. This study addresses that gap through a mixed-methods design that pairs clinician narratives with survey data from the same service.

Methodology

Design

A qualitative-dominant, convergent parallel mixed-methods design was adopted, in which the qualitative and quantitative strands were collected concurrently, analysed separately, and merged at the interpretation stage. The qualitative strand carried the primary analytic weight, while the survey provided breadth and allowed the interview themes to be tested against the wider workforce. Figure 1 illustrates the design.

Setting and participants

The study was conducted in a single metropolitan local health district serving a demographically diverse catchment. Eighteen clinicians spanning nursing and midwifery, medicine and allied health were recruited through purposive sampling for the interviews, and 240 clinical staff completed the cross-sectional survey. Interview participants are identified by the codes C1 to C18. Table 1 summarises the characteristics of both samples, which were broadly comparable in professional mix and experience.

Table 1: Interview participant and survey respondent characteristics

Note. Professional-group rows sum to the sample total; the remaining rows are not mutually exclusive.

Data collection and analysis

Semi-structured interviews of 40 to 60 minutes explored how clinicians understood the two concepts and the enablers and barriers they encountered. The survey combined demographic items with Likert-scale statements on confidence, training, interpreter use and systemic conditions. Qualitative data were examined using framework analysis, which proceeds through familiarisation, construction of a thematic framework, indexing, charting and interpretation, and is well suited to applied health research with a defined policy focus. Survey responses were summarised using descriptive statistics. The study received human research ethics committee approval and was conducted in accordance with national ethical guidelines for research involving Aboriginal and Torres Strait Islander peoples and communities, with oversight from an Aboriginal and Torres Strait Islander reference group that reviewed the interview guide and the interpretation of findings. Participation was voluntary and data were de-identified at collection.

Findings

Framework analysis produced four themes, the frequency of which is reported in Table 2. Survey responses, summarised in Table 3, were consistent with the qualitative account and are drawn on throughout.

Table 2: Frequency of themes across interviews (n = 18)

Note. Participants could raise more than one theme, so counts do not sum to the sample size.

Theme 1: Cultural safety conflated with competence

Most participants used the language of cultural safety but described the practice of cultural competence, treating the two as interchangeable. Sixteen of the 18 clinicians framed safety as something the practitioner achieves by acquiring knowledge, rather than something the patient determines. As one allied health clinician put it, “we do the training and tick the competency, but we rarely ask the patient whether they actually felt safe” (C4). This conflation was visible in the survey, where fewer than half of respondents (46 per cent) felt confident distinguishing the two concepts, as shown in Table 3. The pattern matters because it locates responsibility with the clinician’s knowledge rather than the patient’s experience, the reverse of the recipient-defined standard.

Theme 2: Reliance on informal interpreting

Fourteen participants described routinely working around, rather than with, accredited interpreters when caring for patients with limited English. Time pressure was the dominant explanation: “we use whoever is on the ward who speaks the language, sometimes a family member, because booking an interpreter takes time we do not have” (C11). Several recognised the clinical and ethical risks, including reliance on children to interpret for parents, but described these as difficult to avoid under load. The survey corroborated this account, with only 38 per cent of respondents routinely engaging an accredited interpreter for patients with limited English, despite 62 per cent reporting that they worked with interpreters monthly or more. This is the clearest instance in the data of intention outrunning system support, and it echoes the documented underuse of interpreters in Australian care (Phillips & Travaglia, 2019).

Theme 3: Training builds awareness, not practice

Although most clinicians had completed cultural safety training, few could identify content that had changed their everyday practice. Thirteen participants described a single online module or half-day workshop, valued as a starting point but disconnected from the realities of the ward. “The session was worthwhile, but nothing was different on Monday morning” (C7). Only 41 per cent of survey respondents agreed that training had changed their practice, against 75 per cent who had completed some form of training, a divergence consistent with review evidence that education improves knowledge more reliably than behaviour (Clifford et al., 2015; Truong et al., 2017).

Theme 4: Systemic and structural barriers

The most frequently raised theme, present in 17 of 18 interviews, was that systemic conditions constrained even willing clinicians. Participants pointed to time, staffing, discharge pressure and the absence of continuity as the real limits on culturally safe care: “it is not that people do not care; the system does not give us the time or the staffing to do it properly” (C16). Only 29 per cent of survey respondents felt they had adequate time to provide culturally safe care, as shown in Table 3. Against this constrained picture, participants consistently identified Aboriginal Health Workers and Aboriginal Liaison Officers, and partnerships with community-controlled services, as the strongest enablers of safe care, a view echoed by 92 per cent of survey respondents. Their role was described as extending, not replacing, the responsibility carried by every clinician.

Table 3: Selected survey responses (n = 240)

Discussion

The findings answer the first research question with some consistency: clinicians in this service espoused cultural safety but largely practised cultural competence, treating safety as a provider achievement rather than a patient judgement. This conflation is not merely semantic. It shifts the locus of responsibility away from the institution and towards individual knowledge, which is precisely the move that the recipient-defined standard is designed to prevent (Curtis et al., 2019; NMBA, 2018). Addressing it requires reframing safety as an outcome measured by patients and communities, and building the reflective practice that the professional codes already expect.

The second question is illuminated by the interpreter findings, which represent the sharpest gap between intention and behaviour. Underuse of accredited interpreters is a well-documented Australian problem, and the barriers described here, principally time and availability, match those in the literature (Komaric et al., 2019; Phillips & Travaglia, 2019). Because language access is a concrete and measurable component of safety, it offers services a tractable target: defaulting to accredited interpreters, rather than treating them as an exception, would convert an aspiration into a routine. More broadly, the prominence of systemic barriers supports the structural reading of cultural safety, in which improving care depends on changing services rather than exhorting individuals (Durey & Thompson, 2018; Paradies, 2016).

The third question points towards organisational and systemic reform. The strengths-based finding that Aboriginal Health Workers, Aboriginal Liaison Officers and community-controlled partnerships were the most valued enablers indicates where investment is likely to yield the greatest return, provided these roles are resourced to extend rather than substitute for safe practice across the whole workforce. These directions align closely with existing policy: the multi-level change advocated in reviews of effective interventions (Bainbridge et al., 2015), the planning and workforce commitments of the Cultural Respect Framework (AHMAC, 2016), the accreditation actions of the national standards (ACSQHC, 2017), and the self-determination and partnership principles of Closing the Gap (Australian Government, 2020). The task is less to invent new obligations than to resource and measure those already in place.

Limitations

Three limitations qualify these findings. The study was conducted in a single health district, so the results are transferable rather than generalisable. Both interview and survey data are self-reported and therefore subject to social desirability, which may overstate favourable practice. Finally, and most importantly, the study reports clinician perspectives; the authoritative measure of cultural safety is the experience of Aboriginal and Torres Strait Islander and CALD patients, families and communities, whose voices must guide the next stage of this research.

Conclusion

This study set out to examine how a multidisciplinary clinical workforce understands and enacts cultural competence and cultural safety in the care of Aboriginal and Torres Strait Islander and CALD patients. Its central finding is that clinicians widely endorse cultural safety yet continue to practise cultural competence, and that the gap between the two is held open less by individual attitudes than by systemic conditions, most visibly the underuse of accredited interpreters and the shortage of time. Cultural safety, properly understood, is a relational and organisational achievement defined by those who receive care; competence is necessary but not sufficient. Moving from awareness to safety will require Australian health services to default to accredited interpreting, to resource Aboriginal Health Workers and community-controlled partnerships, and to measure safety through patient experience, giving practical effect to commitments that policy and professional regulation have already made.

References

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