Thesis – Cultural Safety in Hospital Care for Aboriginal and Torres Strait Islander Patients

Abstract

Aboriginal and Torres Strait Islander peoples draw on enduring strengths of family, community and connection to Country, yet many continue to describe hospital care that feels unsafe or unwelcoming. This thesis examined how registered nurses understand and enact cultural safety in the care of Aboriginal and Torres Strait Islander patients in two Australian metropolitan hospitals. A qualitative descriptive design, informed by yarning principles and guided by an Aboriginal and Torres Strait Islander advisory group, was adopted. Ten registered nurses took part in semi-structured interviews of 45-70 minutes, and transcripts were analysed using reflexive thematic analysis. Four themes were developed: relationships before tasks; systems that work against safety; holding onto the Aboriginal Liaison Officer; and education that stops at awareness. The findings position cultural safety as a relational and organisational achievement rather than an individual attribute, with implications for nursing practice, hospital systems, professional education and policy consistent with Nursing and Midwifery Board of Australia expectations.

Introduction

Aboriginal and Torres Strait Islander peoples are custodians of the oldest continuous cultures in the world, sustained by sophisticated systems of kinship, knowledge and care for Country. Australian hospitals, however, have not consistently offered care that honours those strengths. The Australian Institute of Health and Welfare (AIHW, 2024) reports that Aboriginal and Torres Strait Islander patients experience higher rates of potentially preventable hospitalisation and end hospital episodes against medical advice at several times the rate of other Australians. These patterns say little about patients and a great deal about the system; they are signals that hospital environments are not yet experienced as safe.

Cultural safety originated in the scholarship of the Maori nurse and academic Irihapeti Ramsden in Aotearoa New Zealand. Ramsden (2002) argued that the safety of care is determined by the person and family who receive it, not by the professional who delivers it, and that unsafe care includes any action that diminishes or demeans a person’s cultural identity. The concept deliberately shifts attention away from learning about a cultural “other” and towards the power, assumptions and behaviour of clinicians and institutions.

In Australia, cultural safety has moved from aspiration to obligation. The Nursing and Midwifery Board of Australia (NMBA, 2018) embeds cultural safety in the Code of conduct for nurses, and the National Scheme’s health and cultural safety strategy names culturally safe practice as inseparable from patient safety across all registered professions (Australian Health Practitioner Regulation Agency [AHPRA], 2020). The Australian Commission on Safety and Quality in Health Care (ACSQHC, 2017) likewise ties hospital accreditation to specific actions for Aboriginal and Torres Strait Islander health. What remains far less clear is how these commitments are enacted at the bedside.

This thesis aimed to explore how registered nurses in two metropolitan hospitals understand and enact cultural safety when caring for Aboriginal and Torres Strait Islander patients, and to identify what nurses experience as enablers of and barriers to culturally safe care. This extract summarises the literature review, describes the methodology, and presents the findings and their implications for practice, education and policy.

Literature Review

The full review examined Australian and international evidence across four bodies of work, summarised briefly here.

Racism as a determinant of health

Racism is a modifiable determinant of health rather than an unfortunate backdrop. A meta-analysis of 293 studies found consistent associations between self-reported racism and poorer mental and physical health (Paradies et al., 2015). In Victoria, Kelaher et al. (2014) found that a substantial proportion of Aboriginal adults reported racism in health settings within the previous year, with measurable effects on psychological distress. In hospitals, racism operates interpersonally, through dismissive communication and stereotyping, and institutionally, through routines and policies built around the needs of the dominant culture. Naming racism as a determinant places the responsibility for change on services rather than on the people harmed.

Leaving hospital against medical advice

Discharge against medical advice is widely treated as an indicator of how safe hospital care feels. National reporting shows Aboriginal and Torres Strait Islander patients end hospital episodes against medical advice at several times the rate of non-Indigenous patients (AIHW, 2024). A prospective cohort study at Alice Springs Hospital found that self-discharge was driven by communication failures, isolation from family and Country, and distressing ward environments, not by indifference to health (Einsiedel et al., 2013). Read through a cultural safety lens, leaving early is often a rational act of self-protection and obligation to family, and persistent rates should be treated as a system alarm rather than as patient “non-compliance”.

From cultural awareness to cultural safety

The review distinguished cultural awareness, cultural competence and cultural safety. Awareness programs transmit knowledge about cultural practices; competence frameworks add skills but risk reducing culture to a checklist. Cultural safety differs on three points: it examines the culture and power of the clinician and institution, it demands continuing reflexivity rather than one-off training, and its success is judged by the recipients of care (Curtis et al., 2019). Laverty et al. (2017) therefore argue that cultural safety must be embedded in Australia’s main health care standards and accreditation processes rather than left to individual enthusiasm.

Professional codes and regulation

Since 2018, the NMBA code has required nurses to provide care free of racism, to reflect on their own culture and biases, and to work in partnership with Aboriginal and Torres Strait Islander peoples and communities (NMBA, 2018). The National Scheme strategy extends the same expectation across the regulated health professions (AHPRA, 2020). Few Australian studies, however, examine how ward nurses in metropolitan hospitals interpret these obligations in everyday practice. That gap is the focus of this thesis.

Methodology

Design

A qualitative descriptive design was selected to stay close to participants’ accounts. Data collection was informed by the principles of yarning, an Aboriginal and Torres Strait Islander conversational practice established as a rigorous research method by Bessarab and Ng’andu (2010). Because most participants were non-Indigenous nurses, the study is described as yarning-informed rather than as a full yarning methodology: interviews were unhurried, narrative and relational, opening with a social yarn before moving to the research topic, and the approach was reviewed and endorsed by the advisory group. Figure 1 summarises the research design.

Ethics and governance

Ethical approval was granted by the relevant human research ethics committee, including review by its Aboriginal and Torres Strait Islander research subcommittee. The study was designed against the AIATSIS code, which centres Indigenous self-determination, Indigenous leadership, impact and value, and sustainability and accountability (Australian Institute of Aboriginal and Torres Strait Islander Studies [AIATSIS], 2020), and against the National Health and Medical Research Council (NHMRC, 2018) values of spirit and integrity, cultural continuity, equity, reciprocity, respect and responsibility. An advisory group of Aboriginal health professionals and community members shaped the interview guide, recruitment strategy and interpretation of findings, and plain-language summaries were returned to both hospitals’ Aboriginal health units as an act of reciprocity.

Participants and data collection

Purposive sampling recruited ten registered nurses with at least twelve months of clinical experience from a tertiary referral hospital (Site A) and an outer-metropolitan hospital (Site B). Interviews of 45-70 minutes were conducted in private rooms or by video, audio-recorded, transcribed verbatim and de-identified, with participants assigned codes P1 to P10. Participant characteristics are presented in Table 1.

Data analysis

Transcripts were analysed using reflexive thematic analysis (Braun & Clarke, 2019), moving through familiarisation, coding, theme development, review and naming. Candidate themes were tested with the advisory group, and participants received short theme summaries for comment. A reflexive journal recorded analytic decisions throughout.

Positionality

I write as a non-Indigenous registered nurse with twelve years of experience in metropolitan acute care. I cannot stand outside the systems this study critiques, and I have benefited from them. I therefore kept a reflexive journal, examined my assumptions in supervision, and remained accountable to the advisory group for the interpretations offered here. I do not speak for Aboriginal and Torres Strait Islander peoples. This study reports nurse perspectives, which must sit alongside, and be corrected by, the voices of Aboriginal and Torres Strait Islander patients, families and communities.

Findings

The ten participants included eight women and two men, with a median of 10 years since registration (range 3-26) and backgrounds spanning emergency, medical, surgical, renal, maternity, intensive care and rehabilitation nursing, as shown in Table 1. Most had completed only a single online cultural awareness module, typically years earlier.

Table 1: Participant demographics (N = 10)

Analysis developed four themes, summarised in Table 2 and elaborated below.

Table 2: Themes, descriptions and exemplar paraphrases

Theme 1: Relationships before tasks

Every participant located cultural safety in relationships rather than procedures. Nurses whose care was trusted described deliberately slowing the first minutes of an encounter, introducing themselves properly and letting clinical tasks wait. Participants observed that patients often assessed the ward before disclosing pain or worry, and that trust built with one nurse did not automatically transfer to the next, which made continuity of staffing a safety issue. Family presence was consistently framed as a clinical asset, with several nurses noting that care plans agreed with family in the room were far more likely to hold after discharge.

Theme 2: Systems that work against safety

Participants were candid that hospital systems often undid their intentions. Two-visitor limits forced large families into corridors; rigid medication and meal rounds left no space for unhurried conversation; and discharge timing followed bed pressure rather than readiness. Several nurses connected these pressures directly to patients leaving before treatment was complete, describing early departure as a predictable response to an inflexible environment rather than a personal failing, an interpretation consistent with the literature on self-discharge.

Theme 3: Holding onto the Aboriginal Liaison Officer

Aboriginal Liaison Officers were described with uniform respect as advocates, interpreters of the system and sources of calm for patients and staff alike. Yet most participants also admitted contacting the liaison office for almost any concern involving an Aboriginal or Torres Strait Islander patient, and some recognised the contradiction: cultural safety was formally everyone’s obligation but practically delegated to a small team unavailable after hours and on weekends. Participants at both sites wanted liaison roles expanded, while acknowledging that expansion alone would not change their own practice.

Theme 4: Education that stops at awareness

No participant felt their formal preparation matched the expectations of the professional code. Most recalled a brief online module completed at orientation and could not identify content that had shifted their practice. Nurses wanted education that was continuing rather than one-off, delivered by Aboriginal and Torres Strait Islander educators, grounded in local community perspectives, and willing to name racism directly, with structured opportunities to reflect on uncomfortable moments from their own wards.

Discussion

The findings affirm Ramsden’s (2002) insistence that cultural safety is relational at its core. Trust was not an ambient property of the hospital; it was earned in minutes protected for introductions and family, against a historical backdrop in which institutions have been sites of exclusion. Treating relational time as a clinical intervention, rather than a nicety sacrificed under load, aligns with the outcome-focused definition of cultural safety advanced by Curtis et al. (2019): what counts is whether patients and families experience the care as safe.

The second theme shows why individual goodwill is insufficient. Visitor caps, discharge timing and the absence of family spaces are organisational choices, and the Australian evidence on self-discharge suggests those choices carry measurable consequences (Einsiedel et al., 2013). Monitoring discharge against medical advice as a standing cultural safety indicator, reviewed jointly with Aboriginal Liaison Officers and reported through hospital governance, would give practical effect to accreditation guidance already in place (ACSQHC, 2017; AIHW, 2024).

Participants’ reliance on Aboriginal Liaison Officers honours the expertise of that workforce while exposing a structural risk: where cultural safety is delegated, it disappears outside business hours. The professional code makes culturally safe practice the obligation of every nurse (NMBA, 2018), which implies a partnership model in which liaison staff extend, rather than substitute for, safe nursing care. Properly resourcing liaison roles and growing the Aboriginal and Torres Strait Islander nursing workforce, priorities of the National Scheme strategy and of organisations such as the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, are necessary complements (AHPRA, 2020).

Finally, the education findings echo the established critique of awareness-only training (Curtis et al., 2019; Laverty et al., 2017). Education that avoids naming racism cannot interrupt it, and the Australian evidence that racism harms health is difficult to overstate (Kelaher et al., 2014; Paradies et al., 2015). Continuing, reflexive, Aboriginal-led education tied explicitly to the code offers a more defensible model than isolated modules.

Strengths and limitations

Aboriginal and Torres Strait Islander governance, member reflection and a reflexive audit trail strengthen the credibility of the findings. The study nonetheless reports the perspectives of ten nurses at two metropolitan hospitals; it does not represent the experiences of Aboriginal and Torres Strait Islander patients and families, whose accounts remain the authoritative measure of safety. Findings are offered as transferable insights rather than generalisable facts, and future research in this program should be Indigenous-led and centre patient and family voices.

Implications and Conclusion

The findings support four sets of implications for Australian hospitals:

• Practice: protect relational time at first contact, treat family inclusion as part of the clinical plan, and conduct discharge planning as an unhurried, shared conversation.
• Systems: replace rigid visitor caps with family-inclusive policies, provide culturally welcoming spaces, and monitor discharge against medical advice as a routine cultural safety indicator.
• Workforce: fund Aboriginal Liaison Officer coverage across evenings and weekends, and invest in growing the Aboriginal and Torres Strait Islander nursing workforce.
• Education: replace one-off awareness modules with continuing, reflexive, Aboriginal-led education linked explicitly to NMBA (2018) obligations.

Cultural safety asks Australian hospitals a simple question with demanding consequences: do Aboriginal and Torres Strait Islander patients and families say this care is safe? The nurses in this study brought willingness and, often, real skill; what they lacked was a system built to the same standard. Aligning hospital routines, workforce investment and education with the relational logic of cultural safety would honour both the professional code nurses already carry and the strengths that Aboriginal and Torres Strait Islander patients, families and communities bring to their own care.

References

Australian Commission on Safety and Quality in Health Care. (2017). National Safety and Quality Health Service Standards: User guide for Aboriginal and Torres Strait Islander health.

Australian Health Practitioner Regulation Agency. (2020). The National Scheme’s Aboriginal and Torres Strait Islander health and cultural safety strategy 2020-2025.

Australian Institute of Aboriginal and Torres Strait Islander Studies. (2020). AIATSIS code of ethics for Aboriginal and Torres Strait Islander research.

Australian Institute of Health and Welfare. (2024). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2024.

Bessarab, D., & Ng’andu, B. (2010). Yarning about yarning as a legitimate method in Indigenous research. International Journal of Critical Indigenous Studies, 3(1), 37-50.

Braun, V., & Clarke, V. (2019). Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health, 11(4), 589-597.

Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal for Equity in Health, 18, Article 174.

Einsiedel, L. J., van Iersel, E., Macnamara, R., Spelman, T., Heffernan, M., Bray, L., Morris, H., Porter, B., & Davis, A. (2013). Self-discharge by adult Aboriginal patients at Alice Springs Hospital, Central Australia: Insights from a prospective cohort study. Australian Health Review, 37(2), 239-245.

Kelaher, M. A., Ferdinand, A. S., & Paradies, Y. (2014). Experiencing racism in health care: The mental health impacts for Victorian Aboriginal communities. Medical Journal of Australia, 201(1), 44-47.

Laverty, M., McDermott, D. R., & Calma, T. (2017). Embedding cultural safety in Australia’s main health care standards. Medical Journal of Australia, 207(1), 15-16.

National Health and Medical Research Council. (2018). Ethical conduct in research with Aboriginal and Torres Strait Islander Peoples and communities: Guidelines for researchers and stakeholders.

Nursing and Midwifery Board of Australia. (2018). Code of conduct for nurses.

Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A., Kelaher, M., & Gee, G. (2015). Racism as a determinant of health: A systematic review and meta-analysis. PLoS ONE, 10(9), Article e0138511.

Ramsden, I. M. (2002). Cultural safety and nursing education in Aotearoa and Te Waipounamu [Doctoral thesis, Victoria University of Wellington].