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

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Cultural safety is a keystone reform concept intended to improve First Nations Peoples’ health and wellbeing. Are definitions of cultural safety, in themselves, culturally safe? A purposive search of diverse sources in Australian identified 42 definitions of cultural safety. Structuration theory informed the analytical framework and was applied through an Indigenist methodology. Ten themes emerged from this analysis, indicating that cultural risk is embedded in cultural safety definitions that diminish (meddlesome modifications and discombobulating discourse), demean (developmentally dubious and validation vacillations), and disempower (professional prose, redundant reflexivity, and scholarly shenanigans) the cultural identity (problematic provenance and ostracised ontology) of First Nations Australians. We offer four guidelines for future definitional construction processes, and methodology and taxonomy for building consensus based of definitions of cultural safety. Using this approach could reduce cultural risk and contribute to improved workforce ability to respond to the cultural strengths of First Nations Australians.
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Are cultural safety denitions culturally safe? A review of 42 cultural
safety denitions in an Australian cultural concept soup
Mark Lock (Ngiyampaa) ( )
Deakin University
Megan Williams (Wiradjuri)
University of Technology Sydney
Atalanta Lloyd-Haynes (Saltwater, Gomeroi)
Oliver Burmeister
Charles Sturt University
Heather Came
Auckland University of Technology
Linda Deravin (Wiradjuri)
Charles Sturt University
Jennifer Browne
Deakin University
Maria Jose Lopez Alvarez
Troy Walker (Yorta Yorta)
Monash University
Jessica Biles
Charles Sturt University
Danielle Manton (Barunggam)
University of Technology Sydney
Holly Randell-Moon
Charles Sturt University
Sophie Zaccone
University of New England
Renée Otmar
Deakin University
Elizabeth Kendall
Grith University
Tara Flemington
Mid North Coast Local Health District
Aqua Hastings
Australian Catholic University
Jayne Lawrence (Wiradjuri)
Charles Sturt University
Faye McMillan AM (Wiradjuri)
University of New South Wales
Bindi Bennett (Gamilaraay)
Bond University
Research Article
Keywords: cultural safety, First Nations Australians, structuration theory, denition, social policy, Indigenist
Posted Date: December 21st, 2021
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License: This work is licensed under a Creative Commons Attribution 4.0 International License.  Read Full License
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Cultural safety is a keystone reform concept intended to improve First Nations Peoples’ health and wellbeing. Are denitions of cultural safety,
in themselves, culturally safe? A purposive search of diverse sources in Australian identied 42 denitions of cultural safety. Structuration
theory informed the analytical framework and was applied through an Indigenist methodology. Ten themes emerged from this analysis,
indicating that cultural risk is embedded in cultural safety denitions that diminish (meddlesome modications and discombobulating
discourse), demean (developmentally dubious and validation vacillations), and disempower (professional prose, redundant reexivity, and
scholarly shenanigans) the cultural identity (problematic provenance and ostracised ontology) of First Nations Australians. We offer four
guidelines for future denitional construction processes, and methodology and taxonomy for building consensus based of denitions of
cultural safety. Using this approach could reduce cultural risk and contribute to improved workforce ability to respond to the cultural strengths
of First Nations Australians.
Cultural safety is positioned as conceptual solution to address inequities experienced by First Nations peoples worldwide (hereafter, the phrase
‘First Nations Australians’ refers to Aboriginal and Torres Strait Islander peoples in colonial Australia). This movement began with kawa
whakaruruhau (cultural safety) [1] and its philosophical ramparts of ‘reexivity’ [2], ‘culture’ [3], ‘identity’ [4], and ‘power’ [5]. A cultural safety
reform agenda is evident in Canada, Australia, Colombia, and the United States [6–11]. In Australia, cultural safety denitions proliferate–
Australian denitions of cultural safety are contained in Table 1 (Supporting information Table 1)–and our question is: Are cultural safety
denitions culturally safe?
In the Australian social policy context, there is widespread support for implementing cultural safety within a broader cultural reform agenda
[12–14]. Example statements are: cultural safety is seen as being ‘critical to enhancing personal empowerment’ [15], for embedding in
‘Australia’s main health care standards’ [16], and that all Australian government agencies should ‘embed high-quality, meaningful approaches to
promoting cultural safety’ [17]. Rarely in government policy documents is a denition of cultural safety proffered. For example, while two
cornerstone policies for health and for social policy [17, 18] emphasise cultural safety, a denition is absent—and practitioners need to search
elsewhere for clarication.
Denitions as power points to frame meaning
Denitional clarity is important because denitions are ‘power points’ used to frame meaning. The embedded power of a cultural safety
denition appears potent when interpretations become the object of emotional public debate, as for the adverse reactions to the phrase
‘acknowledgement of white privilege’ in one denition (Table 1, Row 16) [19, 20]. Denitions are also powerful for professional accreditation. For
example, the Australian Health Practitioner Regulation Agency (AHPRA) has developed a denition of cultural safety (Table 1, Row 25) that
affects fteen registered health professions and the professional standards of over 800,000 registered health practitioners [21]. However, there
is little identication of how these professions will achieve cultural safety for accreditation beyond acknowledgment and recognition of the
concept [22].
Further, cultural safety denitions are already acknowledged as confusing [23–28]. Therefore, achieving clarity is necessary because, ‘incorrect
perceptions of this concept [cultural safety] may result in cultural risk’ [29]. Risk is agged where, ‘unsafe cultural practices comprise any action
that diminishes, demeans, or disempowers the cultural identity and well-being of the individual’ [30]. In this view, the act of creating a denition
is powerful.
Power of meaning dissolved in a cultural concept soup
The concept of power is a rampart of cultural safety, evident in the process of managing the transfer of power from the practitioner to the client
[31] and in analysing power imbalances [32]. Although there are many facets to consider about ‘power’ and cultural safety [33], in this paper, we
focus on discursive power; that is, the power of meaning-making through denitions. The creation of meaning through writing is powerful in
negative discourse about First Nations Australians [34–36] and in positive strength-based language [36, 37]. Therefore, examining cultural
safety denitions is a worthy exercise because practitioners (i.e., employees or service providers in any social policy domain) use denitions to
frame actions across their career pathways.
Denitional clarity is even more necessary when practitioners, in their search for cultural safety denitions, nd a veritable cultural concept soup
(Fig.2) in Australian social policy discourse. These colliding concepts include: cultural capability [38, 39], cultural learning [40, 41], cultural
competence [42, 43], cultural inclusiveness [44], cultural security [45], and cultural respect [46]. This soup of concept–consisting of numerous
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(and sometimes unknown) ingredients–may inuence practitioners’ capability to deliver culturally safe services by infusing their interpretive
Interpretive schemes as ladle between structure and agency
In understanding the framing of actions and the potential risk of cultural safety denitions, Anthony Gidden’s Structuration Theory (ST) is useful
and is dened as ‘the structuring of social relations across time and space in virtue of the duality of structure’ [47]. In terms of ST, cultural safety
denitions occupy a modality ladle between agency and structure (Fig.1). That is, denitions are structurally positioned in policy discourse; in
various modalities such as practitioner regulations; and in agency through practitioner behaviours. When structural-level reforms require
practitioners to practice cultural safety, they dip a conceptual soup ladle (Fig.2) into various sources, as we do in this study, to inform their
Through the lens of ST, ‘interpretive schemes’ are patterns of behaviour through which agents act in society [48], and are simple rules for sense-
making [49] through which agents mobilise resources [50]. Cultural safety denitions are resources embedded in diverse sources. Giddens
(1984) writes about how power is imbued in language when creating meaning for the interpretive schemas of agents. For example, some argue
that cultural safety inuences attitudes and behaviours [51], which shows that denitions are vehicles of meaning for inuencing attitudes.
However, an important caveat is that the face value of denitions obscures the intentions of their authors. In investigating the context of
denitions (S3 Table 1), through the detailed exploration of research papers, it is apparent that some non-First Nations peoples have deep,
meaningful, and genuine connections that is not questioned here. The denitions offered by First Nations Australian authors are acknowledged
as being embedded in an ethic of advocating for their communities. Our analysis may be seen to undermine the values and spirituality of
authors, but that is certainly not our intention. Our aim is to respectfully highlight the potential detrimental consequences of cultural safety
narratives for First Nations peoples in Australia and offer guidelines for proper denitional development.
Are cultural safety denitions culturally safe? To explore this question, we applied a theoretical orientation of Structuration Theory through an
Indigenist worldview. A group of culturally diverse authors (Supplementary information-Author Biographies) then conducted a purposive search
and thematic analysis of existing Australian cultural safety denitions.
Denitional debates and concept analysis
Denitional papers usually take the form of concept analysis and many related analyses already exist: holistic health [52], wellbeing [53], quality
improvement [54], Aboriginality [55, 56], and culture [57], cultural safety [29, 58], cultural humility [59], for ‘othering’ [60], cultural competence in
healthcare [61, 62], cultural sensitivity [63], and ‘health’ [64]. These analyses are usually devoid of reexivity about knowledge, discourse, power,
and culture. This body of research is also decient in First Nations Peoples’ worldviews in informing the underlying epistemological framework.
Our methodology addresses these gaps by drawing information from diverse sources (in contrast to only peer-reviewed literature), applying
theoretical specicity (Structuration Theory) and ensuring reexivity by and among authors particularly when working at the cultural interface
Theoretical orientation
The appeal of ST is its relational ontology, is seen in the denition of structuration (above), and which is seen in the ethic of ‘strong
relationships’ in Australian social policy, such as in calls for a First Nations Australian voice to Parliament [66], health systems reforms [67], and
cultural safety discourse [68–72]. The ‘structuration of social relations’ in ST, is evidence in restructuring social policy and systems for First
Nations Australians is noted in the 2020 National Agreement on Closing the Gap, which ‘signalled a new way of working to close the gap’ in life
expectancy and other indicators between First Nations and other Australians [17], and restructuring is a routine political process in social
policies relevant to First Nations Australians [73–77].
Giddens (1984) does not prescribe rules for converting structuration theory into a methodological framework, and a key task is to unpack ST
concepts into domains relevant to the eld of enquiry [78]. The framework for this study (Fig.1) shows Giddens’ diagram of structuration (1984:
29) on the right-hand side with the domains of agency (with concepts of communication, power, and sanction); modality (meaning through
interpretive schemes, facility, and norm); and structure (as rules and resources through signication, domination, and legitimation).
Fig.1: Transformation of structuration theory into a heuristic for analysis of cultural safety denitions
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Underlying this heuristic is the ‘duality of structure’, where ‘social structures are both constituted by human agency, and yet at the same time are
the very medium of this constitution’ [47]. That is, in unpacking ST concepts, legislation enables social policy systems which are transformed
into a governance context for organisations within which practitioners provide services to clients (left-hand side, Fig. 1). This is a mutually
interacting framework whereby agents (practitioners and citizens) in their interactions, simultaneously draw-on and inuence social policy
systems. They do so, according to Giddens, through routine social interactions that he describes through structuration concepts (identied in
Fig. 1, and described below):
Structures – are rules and resources which actors draw upon and use in the communication of meaning:
a. signication—the ‘symbolic orders/modes of discourse’ [47] such as denitions of cultural safety positioned in wider discourse of
cultural concepts,
b. domination – how codes of signication—such as racialisation [79]—are enacted using resources,
c. legitimation – the ‘social systems for normative regulation’ [79], such as reected in legal institutions [47].
Modality - refers to, for example, writing and conversation as modalities of signication [80]:
a. interpretive scheme – as described above,
b. facility – refers to the access of ‘media’ that agents use to develop stocks of knowledge, such as the use of the English language as a
facility for the communication of meaning, or accreditation standards as a facility for conveying practice expectations,
c. norm – evident when an actor needs to explain their actions by drawing on social norms such rules of ‘race norms’ [79].
Agency – the capability, often reected within the individual, to take part in and inuence routines of daily life [47]:
a. communication and power – including communication of denitions, which are themselves power points of inuence, and
b. sanction – the restraining aspects of power experienced as, for example, the use of ‘overt physical violence to the expressions of mild
disapproval’ [47].
Giddens (1984) makes clear that these concepts are nondeterministic abstractions useful in the organisation of analysis of social interactions.
These understandings provided a sensitising lens for the study rather than stepwise instructions for empirical analysis.
Data collection
Australian denitions of cultural safety were identied by searching different sources (December 2020 to July 2021, with supplemental
searches afterwards to detect new denitions) using the keywords of ‘denition’ and cultural safety, and their Boolean operators. The webpage
search string was ‘site:au denition “cultural safety” dene “culturally safe”’, which returned hundreds of thousands of pages, of which the rst
50 pages (500 items) were scanned for results. This meant that a single click on the hyperlink opened to the relevant page referencing the
keywords. We also searched academic database platforms—Informit (e.g., ATSIHealth, APAIS-ATSIS; Indigenous Collection); CINAHL Complete;
PubMed; Scopus, Medline, ProQuest (Australia & New Zealand Database), EBSCOhost, and OVID; and with parameters of ‘full text’ and ‘no date
range. All Australian-only sources were included with denitions extracted into a table where a taxonomical notation (Appendix 1, Table 1) was
devised to allow cross-reference and comparison between denitions.
Thematic development
The thematic development process followed open-ended ‘online’ yarning [81, 82] between the authors, and in larger groups that included authors
and others in our networks. This identied the theory and research question. It was followed by data collection and analysis, and cycles of
written feedback. This process is aligned with an Indigenist methodology of knowledge production, and especially responds to the call that
‘Indigenous perspectives must inltrate the structures and methods of the entire research academy’ [83]. This demands an ethic of resistance as
an emancipatory imperative in Indigenist research, the cultural and political integrity of Indigenous research, and the privileging of First Nations
Australians’ knowledge and voices in research design [84]. Hence, these values are imbued in the category names for each theme.
The extracted denitions are presented in Appendix 1 (Table 1), and the resulting themes are shown diagrammatically as a metaphorical
cultural concept soup (Fig.2). In Fig.2, diverse stakeholders, consciously or unconsciously, bring with them different cultural denitions to their
work, and use what they think is the ‘cultural safety ladle’ to stir the soup. The thematic aromas that arise from the soup diffuse into social
policy discourse to create ethereal meanings about which cultural concept–or group of concepts–are crucial to the success (or failure) of
cultural reforms.
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Denitional diversity
Our search yielded 42 denitions of cultural safety (Table 1) in social policy about First Nations Australians. The denitional diversity appeared
to begin with the rst published denition of cultural safety, namely Eckermann’s 1992 book ‘Binan Goonj: Bridging Cultures in Aboriginal
Health’, as reprinted in 1994 [85]. Hence, it is the rst entry in Table 1 (Row 1). A taxonomy was created for tracking the source of denitions
AKE-dCSaf-AU (Ann Katrin-Eckermann, denition of cultural safety, Australia). The second denition is Robyn Williams’, published in the journal
article, ‘Cultural Safety – What Does it Mean for Our Work Practice?’ (Williams, 1999): RW-dCSaf-AU (Table 1, Row 2).
Numerous modications occur to Williams’ denition over the years, which is not the case for Eckermann’s denition. There are seven
modications to Williams’ denition (Table 1, Rows 3, 11, 15, 17, 19, 23, and 26). In our taxonomy, MBS-dCSaf(RW-dCSaf2)-AU, means that
Maryann Bin-Sallik modied Robyn Williams’ denition. This occurs were Bin-Sallik extracted a paragraph from an unpublished paper of
Williams’ [86] and reframed the paragraph (located in Appendix 3, p. 15) as Williams’ denition [87]. Other denitions of cultural safety (not
Williams’ or Eckermann’s) were also modied by subsequent authors (Table 1, Rows 21, 24, 28, and 42).
The denitions also reect diverse points and pathways within health (e.g., policy, hospital, nursing and midwifery, health workers, doctors,
health equity, alcohol programs, health practitioners, women’s safety, general practice, suicide prevention), family and child safety (e.g., social
work, education system, child care and young people, family violence), the mining industry, legal centres and legal aid, workplace health and
safety, Australian trade and investment, Australian rules football, and program evaluation and libraries. This denitional diversity holds
implications for ‘governance’ and ‘legitimation’ (Fig.1) in the sense that denitions are vehicles of meaning for the governance actions driving
organisational reforms that ow on to practitioner service delivery.
Developmentally dubious
Except for the AHPRA denitional development process (Table 1, Row 25), the processes for constructing denitions were opaque (dubious) in
that no empirical, theoretical, or methodological processes are described for their construction (other than the fact that some draw-on earlier
authors). There are no publicly available explanations of how denitions were developed, with whom they were developed, and whether any
First Nations Australian community engagement occurred during the process of delineation. This lack of engagement and culturally informed
process has implications for the ‘interpretive scheme’ concept of structuration (rst level of Fig.1) because community needs are not informing
denitions and, thereby, guidance for practitioners to respond to community needs.
Problematic provenance
The cultural provenance of the denitions shows that many (n=14) (Table 1) are transformed from kawa whakaruruhau, a Māori First Nations
concept from Aotearoa/New Zealand, and not from a concept of First Nations Australians (Table 1, Rows 1, 2, 3, 7, 11, 14, 15, 17, 19, 20, 23, 26,
27, and 30), such as the Wiradjuri concept of Nyaa-bi-nya: to examine, try, and evaluate [88]. Almost half of the denitions (n=20, Table 1, 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 (Table 1, Rows 21,
22, 24, 25, 28, 34, 39, 41, and 42) whose cultural origins are Australian and New Zealand (but not kawa whakaruruhau). This has implications
for the ‘signication’ concept of structuration (Fig.1) and social policy systems, because such ‘problematic provenance’ suggests the possibility
of cultural appropriation [89] and signies the devaluing of First Nations Australian ways of knowing.
Ostracised ontology
First Nations Australians are among the world’s oldest living cultures [90] and have local language terms for health and wellbeing. For example,
there is Kaurna language: Yaitya Purruna/‘our own health and wellbeing’ [91]; Wiradjuri language: Waluwin/‘health and wellbeing’ [92]; Walpiri:
wankaru/ ‘to promote and strengthen the life of Aboriginal people as a means of ensuring their survival and growth’ [93]; Aranda language:
Kurruna Mwarre Ingkintja/‘good spirit men’s place’ [94], and Wirringa Baiya/‘women speak’ [95]. None of the denitions in Table 1 make
reference to First Nations Australian languages to indicate that their meanings are based on translation of local worldviews. This ‘ostracised
ontology’ has implications for the ‘domination’ concept of structuration and ‘legislation’ (Fig.1, Level 1) because infusing legislation with
cultural power should be based on the strengths of First Nations Australian cultures.
Validation vacillations
Validation involves stakeholder assessment of measurement tools to ensure they are culturally acceptable [26, 96]. First Nations Australians
challenge the underlying Western cultural construct of many instruments [97–100]. None of the denitions (Table 1) come with information
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about their methodologies of cultural validation: what was the instrument used to validate their process and their denitions? Such ‘validation
vacillations’ have implications for the ‘sanction’ concept of structuration (Fig.1, Level 3) and the types of social services provided because who
decides (sanctions) a service is culturally safe are First Nations Australians, who expect those services to reect their cultural values.
Professional prose
Based on the individual (as opposed to organisational) authors the denitions are rendered in English and through the lenses of non-First
Nations peoples (n=7, Table 1, Rows 1, 2, 14, 23, 30, 31, and 33) who were professionals with higher education qualications, and who were
employed by mainstream organisations. Similarly, other denitions were authored by First Nations experts (n=5, Table 1, Rows 9, 14, 26, 29, and
39). Even the First Nations authors are based in similar settings, though only a few authors are First Nations Australians (Maryann Bin-Sallik,
Gregory Phillips, BJ Newton, Larissa Behrendt, and Sharon Gollan), but also with professional education and qualications.
The result is where ‘professional prose’ structures the locus of power to rest with professionals rather than First Nations communities or service
users. It is notable that almost all (except Row 30, Table 1) denitions developed by individual authors avoid referencing their own professional
standing and power, despite the philosophical rampart of ‘reexivity’. Other denitions reference professional/provider power (n=3, Table 1,
Rows 21, 27, 30) and power imbalances/sharing/differentials (n=10, Table 1, Rows 8, 10, 16, 24, 25, 28, 34, 37, 40, and 41). This has
implications for the ‘agency’ and ‘power’ concepts of structuration theory (Fig.1, Level 3) because of the power of writing in creating meaning
that inuences practitioner attitudes and their practices.
Scholarly shenanigans
The denitions of cultural safety also suffer poor standards of attribution and citation (n=10, Table 1; Rows 2, 3, 12, 15, 17, 19, 23, 28, 40, and
41). Examples of ‘scholarly shenanigans’ are common. For instance, in an article about the importance of cultural safety to social work policy,
Thompson and Duthie [101] quote Williams’ (1999) denition but attribute it to an article by Ramsden (1992), which does not contain any
denition [102], and this shenanigan also occurs in an article by Elvidge and colleagues [27]. The denition AIHW-dCSaf (Table 1, Row 27) is
incorrectly referenced to Papps and Ramsden [103], which is also incorrectly cited as the source of a so-called ‘denition’ (Table 1, Row 41).
There is one incorrect citation of Williams’ (1999) denition of cultural safety as Williams (2008) (Table 1, Row 19) and an internet search
revealed n=124 instances where this incorrect reference was repeated [i.e., found by entering the incorrect reference: ‘Williams, R. (2008).
Cultural safety: what does it mean for our work practice?’]. The denition by Williams (1999) is often attributed to Eckermann and colleagues
(1994) (Table 1, Row 2, 23, and 26) [see for example 104]. The work is also misattributed in The National Best Practice Framework for
Indigenous Cultural Competency in Australian Universities [43], and in academic articles [105, 106]. If scholars checked primary sources, they
would have seen Eckermann’s denition (Table 1, Row 1) bears no resemblance to Williams’s denition (Table 1, Row 2). This has implications
for the ‘modality’ and ‘facility’ concepts of structuration (Fig.1, Level 2) because the inaccuracies are repeated in cultural safety discourse, a
facility of meaning.
Meddlesome modications
The denitions contain different ingredients (Table 1) with no explanation for their selection. In the health domain, these ‘meddlesome
modications’ of the concepts not only risk stultifying the cultural avour of the soup, but also affect how denitions are interpreted. The
modications can be seen in the selection of key ingredients excised from each denition:
a. recognised, assured, reects, you/your culture, language, customs, attitudes, beliefs, and preferred ways (AKE-dCSaf, Row 1)
b. determined, individuals, families, communities, practise, reection, health practitioner, knowledge, skills, attitudes, behaviours, power
differentials, safe, accessible, responsive, and racism (AHPRA-dCSaf, Row 25)
c. dened, health consumer, individual, experience, care, ability, access services, and raise concerns (AIHW-dCSaf, Row 27)
d. environment, diverse background, feels, valued, and accepted (LB-dCSaf, Row 29)
The meddlesome modications hold implications for the ‘communication’ concept of structuration (Fig.1) with the rationale that the selection
of words (and who selects them) is signicant for the communication of meaning to stakeholders and their organisations. Interestingly, the
concepts of power (n=7), culture (n=12), reexivity (n=6), and identity (n=20) are non-uniformly distributed and show selective word choices by
Discombobulating discourse
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The denitions in Table 1 contain a confusing of meanings. For example, ANMC-dCSaf states ‘regardless of race or ethnicity’ (Table 1, Row 4)
whereas Eckermann’s denition implores ‘the need to be recognised within the healthcare system’ (Table 1, Row 1) and CATSINAM-dCSaf (Table
1, Row 16) states that it, ‘represents a key philosophical shift from providing care regardless of difference, to care that takes account of peoples’
unique needs’. Thus, while cultural safety may be a commonly used phrase, the ‘discombobulating discourse’ and denitional diversity within
different policy points demonstrates the potential risk of divergent meanings through the ‘interpretive scheme’ concept of structuration and
‘practitioner-client interaction’ (Fig.1, Levels 2 and 3). Then, when communicating with clients, practitioners may speak from a standpoint of
either disregard or regard for race and justify both as correct choices by referencing the relevant denition.
Redundant reexivity
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).
This invisibility of authors’ cultural identities prevents understanding of their cultural worldviews through which the denitions were developed.
There are also whole-of-organisation authors (n=23; Table 1, 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. In contrast, four Aboriginal
community controlled organisations offered denitions (VACCA in Row 6, VACCHO in Row 8, CAPSC in Row 17, and SNAICC in Row 18). None
of the whole-of-organisation denitions are accompanied by reexive statements about the philosophical implications of infusion their different
governance structures with cultural safety.
Overall, the organisational authorship processes, and the resulting cultural safety denitions, lack grounding in the frequent call for reexivity so
often made by authors of cultural safety denitions. This has implications for the ‘norm’ concept of structuration (Fig.1, Level 2) because it
signies a convention for reexivity to be an optional, rather than essential, feature of cultural safety.
Fig.2: Cultural concept soup with thematic results
The ten themes emanating from the cultural concept soup (Fig.2) whiff of cultural risk. This analysis substantiates the claim that the
conceptual clarity of cultural safety is being diminished [107], particularly through the morphing of its original intent [108], and thus undermines
its inuence as a transformative moral discourse [8]. Cultural risk refers to ‘any action’ which may diminish, demean, or disempower cultural
identity – including the action of creating denitions. The cultural risk in denitions was assessed using Giddens’ Structuration Theory as the
analytical frame, and structuration concepts that have been used to tease out the implications for Australian cultural safety discourse.
Structural implications
Australian Practitioners searching for guidance on cultural safety are likely to be confronted with at least 42 denitions of cultural safety.
Although denitional diversity may be consistent with the philosophy of cultural safety, the increased availability of inconsistent information
could be problematic in moving from denition to practice. As Ramsden (1990) wrote, ‘like ethical safety, cultural safety must be interpreted
according to each event’ [109]. This view legitimises diverse interpretations of cultural safety philosophy, which aligns with the cultural diversity
of First Nations Australians, but it also presents cultural risks.
Interestingly, cultural diversity is not reected in the problematic provenance of the denitions, where ‘provenance’ is the notion that an idea
seeded in a locale (following Giddens) has unique properties of cultural context that cannot be transplanted to different environments. It is
problematic for Australian social policy actors to signify Māori ontology embedded in cultural safety [89] over First Nations Australians’
Country-specic ontologies that need to be directing and informing policy and practice [110]. No stronger signication of cultural provenance is
seen elsewhere than in the expressions of cultural voice of First Nations Australians through their traditional languages [111].
In terms of domination, the denitions inect an ostracised ontology that disavows First Nations Australians’ worldviews. This norm is
consistent with current Australian debates about whether or not to embed a First Nations Australian voice in Australia’s national Parliament
through Constitutional reforms [112]. The debates centre on the fundamental right [113] of First Nations Australians’ cultural values to direct
legislation, to challenge the dominance of non-First Nations Australians’ worldviews, and to infuse decisions about rule-making and resource-
Page 9/17
allocation. Therefore, calls to legislatively embedded cultural safety in healthcare standards [16] could enable further disempowerment, and this
risk stimulates the need for better translation of First Nations Australians’ worldviews in developing cultural denitions.
Modality implications
Almost all denitions of cultural safety are developmentally dubious because, in their construction, no information is given to evidence the
genuine engagement with First Nations Australian consumers and community-led organisations. This undermines the denitions’ legitimacy for
incorporation into stocks of knowledge and interpretive schemes. The partial exception is the AHPRA denition (Table 1, Row 23) which was
based on a public consultation process, and both the process and outcomes were published (Australian Health Practitioner Regulation Agency,
2019a, 2019b). However, behind all denitions is a validation vacillation that disrespects the process of cultural validation wherein ‘theories and
instruments need to be ‘grounded’ within that culture, if they have to be considered valid’ [114]. These problems pivot on the modality axis to
inuence the structure and agency of cultural safety denitions, which occur lumped in with the cultural concept soup (Fig.2) where other
cultural concepts, such as cultural competence, also suffer from ‘ambiguity and lack of denition’ [115].
Furthermore, scientic rigour is lacking in the development of these denitions, as evident in the scholarly shenanigans. Scholars are called on
to construct reliable evidence [116] that practitioners interpret and embed into their attitudes. If scholarly publications about First Nations
Australians’ cultural safety are of poor quality, it is axiomatic that higher education curriculum and professional training and practice will suffer
[117]. This situation points to the facility of the evidence base being faulty, which then ramies through each related concept of structuration.
Practitioners, expected to practice evidence-based care [118], may not know to question the quality of cultural safety denitions, and if they are
non-First Nations, may not believe they have any authority to do so.
Agency implications
One responsible line of questioning for practitioners would be to ask if a denition they adopt/ascribe to ‘ts with the familiar cultural values
and norms of the person[s] accessing the service’ (VACCHO-dCSaf, Table 1, Row 8), because there is scant evidence that denitions reect the
cultural voices of First Nations Australians. The risk is that the 42 denitions and their discombobulating discourse inuences practitioners’
interpretive schemes and erode condence in their interactions with First Nations clients.
The implication of denitional diversity and discombobulated discourse should not be under-estimated. The Australian Nursing and Midwifery
Standards of Practice states that, ‘guidance around cultural safety in the codes sets out clearly the behaviours that are expected of nurses and
midwives’ [119]. Achieving clarity of behaviours is illogical when practitioners face confusing messages and meanings embedded in diverse
denitions. Reliable guidance is, moreover, complicated by the shenanigans of scholars, their meddlesome modications, and their redundant
reexivity about the power of words.
The selection of words and who selects them are signicant for the communication of meaning in interaction, as evidenced in debates about
holistic health versus Western medicine [52]. For example, a practitioner may wonder about ‘decolonisation’ and ‘acknowledgement of white
privilege’ being in one denition (NMFBA-dCSaf, Table 1, Row 24) but not in another denition (ANMC-dCSaf, Table 1, Row 4). Considered word
choice is necessary in constructing meaning to respect cultural provenance–witness the cultural power of kawa whakaruruhau/cultural safety
Word choice through professional prose dominates transformations of the philosophy of cultural safety, and risks being a conscious or
unconscious discursive tactic to reinforce professional power. This contrasts with human rights-informed literature that asserts the importance
of addressing power imbalances between practitioners and clients—as AIHW-dCSaf states that cultural safety, ‘is dened by the health
consumer’s experience’ (Table 1, Row 26). However, it is nursing health professionals who have led cultural safety politics [119], in an Australian
political environment of consumer and community-based advocacy [74, 120, 121]. This also indicates and an incongruent interplay between
transitions from the oral narratives historically practiced about caregiving in health care [52], compared with written narratives from those in
more powerful (often scholarly) positions, which may lead to interpretive differences in meaning. Therefore, a key challenge for practitioners is
to reect on the balance of cultural identity, profession power, and community voices evident (or not) in denitions.
Several denitions of cultural safety show that the assessment of a safe service needs to be dened by those who receive the service (Table 1,
NATSIHWA-dCSaf, Row 10; LIME-dCSaf, Row 21; AIHW-dCSaf, Row 27; NTH-dCSaf, Row 40). First Nations Australians’ community engagement
should occur at the time of creating the denitions of cultural safety, not only at the point of assessing the outcomes of services. The absence
of cultural validation in denitions developed by experts and professionals, sanctions (Fig.1) an ethic of excluding clients’ voices. This ethic
disabuses governance of client agency and their feelings about what is culturally safe.
Page 10/17
Denitions enable cultural risk
Based on this analysis of publicly available online documents, Australian cultural safety denitions – on face value – are actually culturally
unsafe. The themes show that cultural risk is embedded in cultural safety denitions that diminish (meddlesome modications and
discombobulating discourse), demean (developmentally dubious and validation vacillations), and disempower (professional prose, redundant
reexivity, and scholarly shenanigans) the cultural identity (problematic provenance and ostracised ontology) of First Nations Australians.
Clarifying the cultural concept soup
Clarication is important to pursue because cultural safety is but one of many cultural concepts circulating in the Australian cultural reform
agenda [12], and is also subject to criticism from transcultural nursing proponents, ‘the notion of cultural safety is conceptually problematic,
poorly understood, and under-researched’ [122]. Furthermore, cultural safety is conated into many other terms including cultural security [123],
cultural competence [124], and cultural capability [125]. Our methodology, particularly the use of Structuration Theory, could lead to better
evaluation of cultural training programs through improved methodological rigour [126] applied to the development of denitions that inform
training program design.
Reective guidelines
We serve-up four guidelines for the development and use of cultural safety denitions, namely to reect on language power, to describe the
process, to epitomise First Nations Australians’ community voices, and to ensure cultural rigour.
1. Reect on the power of language: Language is a weapon for creating meaning to control and shape social policy—be guided by examples
of genuine writing between First Nations and non-First Nations authors, such as Povey and Trudgett (2019), and the work of academics
who apply cultural quality appraisal tools [127].
2. Describe the process: Clearly explain the steps used in denition development, as recently outlined [128]. The AHPRA process is an example
of transparency and accountability through publications [129-132].
3. Epitomise the cultural voice: The voice of First Nations Australians is available through oral forms of communication, such as yarning
[133], the results of which could be to focus on the articulation of local First Nations’ languages and their meaning for cultural safety [134].
4. Ensure cultural rigour: The cultural rigour [135] of the denitional development process must be guided by relevant critical thinking tools
[88, 136, 137], cultural validation methods [96], and Indigenous theories [65, 83, 138].
Future research is needed to assess the interpretations of cultural safety denitions in the real-world machinations of inter-cultural
communications: how they are used in practice, if they affect interactions, and if First Nations Australians feel they promote cultural safety.
This study is based on a purposive search and rigorous systematic reviews may nd even more Australian denitions. While Structuration
Theory has provided a new perspective from which to view cultural safety denitions, it is a western sociological concept not developed with or
by colonised peoples. Caution must also be exercised to avoid over-ascribing the signicance of denitions as deterministic of human
This study revealed ten cultural risks based on an analysis of 42 denitions of Australian cultural safety gathered from an online search of
diverse sources. Our ndings suggest the publicly available documents served up to Australian practitioners represent a ‘cultural concept soup’
emanating confusing aromatic themes. This may affect practitioners’ application of cultural safety with First Nations Australian clients, who
could be placed at cultural risk. We propose a methodology and taxonomy to advance a social science of denitional analysis. Open to
scholarly debate, our intention is to contribute to building a high-quality evidence base so that claims about cultural safety can rest on culturally
rigorous methodology. This could reduce cultural risk and contribute to improved workforce ability to address the inequities experienced by First
Nations Australians.
Page 11/17
Thank you to Ms Sophie Kinna for her research assistance, Ms Jodie Lea Matire for her cultural perspectives in writing and publishing, and Ms
Janine Dunleavy for deadly critical thinking about Aboriginal cultural anthropology.
Competing interests
The authors declare no competing interests.
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Table 1 is available in the Supplemental Files section
Figure 1
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Transformation of structuration theory into a heuristic for analysis of cultural safety denitions
Figure 2
Cultural concept soup with thematic results
Supplementary Files
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Introduction Indigenist evaluation is emergent in Australia; the premise of which is that evaluations are undertaken for Indigenous, by Indigenous and with Indigenous people. This provides opportunities to develop new models and approaches. Exploring a collective capability approach could be one way to inform an Indigenist evaluation methodology. Collective capability suggests that a base of skills and knowledges exist, and when these assets come together, empowerment and agency emerge. However, collective capability requires defining as it is not common terminology in population health or evaluation. Our aim is to define the concept of collective capability in Indigenist evaluation in Australia from an Australian Indigenous standpoint. Methods and analysis A modified Rodgers’ evolutionary concept analysis will be used to define collective capability in an Australian Indigenous evaluation context, and to systematically review and synthesise the literature. Approximately 20 qualitative interviews with Aboriginal and Torres Strait Islander knowledge holders will clarify the meaning of collective capability and inform appropriate search strategy terms with a consensus process then used to code the literature. We will then systematically collate, synthesise and analyse the literature to identify exemplars or models of collective capability from the literature. Ethics and dissemination The protocol has approval from the Australian Institute of Aboriginal and Torres Strait Islander Studies Ethics Committee, approval no. EO239-20210114. All knowledge holders will provide written consent to participate in the research. This protocol provides a process to developing a concept, and will form the basis of a new framework and assessment tool for Indigenist evaluation practice. The concept analysis will establish definitions, characteristics and attributes of collective capability. Findings will be disseminated through a peer-reviewed journal, conference presentations, the project advisory group, the Thiitu Tharrmay reference group and Aboriginal and Torres Strait Islander community partners supporting the project.
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Background Aboriginal and Torres Strait Islander Australians experience persistent health and social inequities. Chronic conditions, many of which are diet-related, are leading contributors to the burden of disease and health inequity in Australia. First Nations Peoples have the right to be involved in all policy decisions affecting them. This review aimed to synthesise Aboriginal and Torres Strait Islander Peoples’ concerns and priorities about food and nutrition in order to inform policies to improve health equity. Methods MEDLINE, CINAHL, Informit and Google Scholar were systematically searched to identify qualitative studies–published from January 2008–that included data from Aboriginal and/or Torres Strait Islander Peoples about their concerns and priorities related to food and nutrition. Data were extracted from included studies using a pre-determined template and study quality was assessed using the Aboriginal and Torres Strait Islander Quality Appraisal Tool. Qualitative findings were synthesised using inductive thematic analysis and categorised based on an ecological model of health. Results Twenty-one studies were included. Key factors influencing food and nutrition were identified across all levels of the ecological framework. These included interpersonal and institutional racism, junk food availability and marketing, food accessibility and affordability, housing conditions, food knowledge and cooking skills, and connection to family and culture. Conclusions Documenting Aboriginal and Torres Strait Islander Peoples’ lived experiences of the colonised food system is one step necessary for informing policy to tackle food and nutrition inequities. Based on existing qualitative research, food and nutrition policymakers should prioritise building a supportive food environment by focusing on self-determination; ensuring access to healthy, affordable food and safe housing; and by eliminating systemic racism.
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Background Developing since colonisation, Australia’s healthcare system has dismissed an ongoing and successful First Nations health paradigm in place for 60,000 years. From Captain James Cook documenting ‘very old’ First Nations Peoples being ‘far more happier than we Europeans’ and Governor Arthur Phillip naming Manly in admiration of the physical health of Gadigal men of the Eora Nation, to anthropologist Daisy Bates’ observation of First Nations Peoples living ‘into their eighties’ and having a higher life expectancy than Europeans; our healthcare system’s shameful cultural safety deficit has allowed for an Aboriginal and Torres Strait Islander child born in Australia today to expect to live 9 years less than a non-Indigenous child. Disproportionately negative healthcare outcomes including early onset diabetes-related foot disease and high rates of lower limb amputation in Aboriginal and Torres Strait Islander Peoples contribute to this gross inequity. Main body In 2020, the Australian Health Practitioner Regulation Authority released the National Scheme’s Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020–2025 - empowering all registered health practitioners within Australia to provide health care to Aboriginal and Torres Strait Islander Peoples that is inclusive, respectful and safe, as judged by the recipient of care. This recently released strategy is critically important to the podiatry profession in Australia. As clinicians, researchers and educators we have a collective responsibility to engage with this strategy of cultural safety. This commentary defines cultural safety for podiatry and outlines the components of the strategy in the context of our profession. Discussion considers the impact of the strategy on podiatry. It identifies mechanisms for podiatrists in all settings to facilitate safer practice, thereby advancing healthcare to produce more equitable outcomes. Conclusion Aboriginal and Torres Strait Islander Peoples access health services more frequently and have better health outcomes where provision of care is culturally safe. By engaging with the National Scheme’s Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy, all registered podiatrists in Australia can contribute to achieving equity in health outcomes for Aboriginal and Torres Strait Islander Peoples.
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Objective: To highlight the emerging ethos of cultural rigour in the use of critical appraisal tools in research involving First Nations peoples. Methods: Critical reflection on recent systematic review experience. Results: The concept of cultural rigour is notably undefined in peer-reviewed journal articles but is evident in the development of critical appraisal tools developed by First Nations peoples. Conclusions: Conventional critical appraisal tools for assessing study quality are built on a limited view of health that excludes the cultural knowledge of First Nations peoples. Cultural rigour is an emerging field of activity that epitomises First Nations peoples' diverse cultural knowledge through community participation in all aspects of research. Implications for public health: Critical appraisal tools developed by First Nations peoples are available to researchers and direct attention to the social, cultural, political and human rights basis of health research.
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Background Cultural safety, whereby health professionals respect and promote the cultural identity of patients, could reduce intercultural tensions that hinder patient access to effective health services in Colombia. Game jams are participatory events to create educational games, a potentially engaging learning environment for Millennial medical students. We set out to determine whether medical student participation in a game jam on cultural safety is more effective than more conventional education in changing self-reported intended patient-oriented behavior and confidence in transcultural skills. Methods We conducted a parallel-group, two-arm randomized controlled trial with 1:1 allocation. Colombian medical students and medical interns at University of La Sabana participated in the trial. The intervention was a game jam to create an educational game on cultural safety, and the reference was a standard lesson plus an interactive workshop on cultural safety. Both sessions lasted eight hours. Stratified randomization allocated the participants to the intervention and control groups, with masked allocation until commencement. Results 531 students completed the baseline survey, 347 completed the survey immediately after the intervention, and 336 completed the survey after 6 months. After the intervention, game jam participants did not have better intentions of culturally safe behaviour than did participants in the reference group (difference in means: 0.08 95% CI − 0.05 to 0.23); both groups had an improvement in this outcome. Multivariate analysis adjusted by clusters confirmed that game jam learning was associated with higher transcultural self-efficacy immediately after the intervention (wt OR 2.03 cl adj 95% CI 1.25–3.30). Conclusions Game jam learning improved cultural safety intentions of Colombian medical students to a similar degree as did a carefully designed lecture and interactive workshop. The game jam was also associated with positive change in participant transcultural self-efficacy. We encourage further research to explore the impact of cultural safety training on patient-related outcomes. Our experience could inform initiatives to introduce cultural safety training in other multicultural settings. Trial registration Registered on ISRCTN registry on July 18th 2019. Registration number: ISRCTN14261595 .
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Background: Indigenous peoples are among the most marginalized groups in society. In the Philippines, a new policy aimed at ensuring equity and culture-sensitivity of health services for this population was introduced. The study aimed to determine how subnational health managers exercised power and with what consequences for how implementation unfolded. Power is manifested in the perception, decision and action of health system actors. The study also delved into the sources of power that health managers drew on and their reasons for exercising power. Methods: The study was a qualitative case study employing in-depth semi-structured interviews with 26 health managers from the case region and analysis of 15 relevant documents. Data from both sources were thematically analyzed following the framework method. In the analysis and interpretation of data on power, VeneKlasen and Miller's categorization of the sources and expressions of power and Gilson, Schneider and Orgill's categorization of the sources and reasons for exercising power were utilized. Results: Key managers in the case region perceived the implementation of the new Indigenous health policy as limited and weakly integrated into health operations. The forms of power exercised by actors in key administrative interfaces were greatly influenced by organizational context and perceived weak leadership and their practices of power hindered policy implementation. However, some positive experiences showed that personal commitment and motivation rooted in one's indigeneity enabled program managers to mobilize their discretionary power to support policy implementation. Conclusion: The way power is exercised by policy actors at key interfaces influences the implementation and uptake of the Indigenous policy by the health system. Middle managers are strategic actors in translating central directions to operational action down to frontlines. Indigenous program managers are most likely to support an Indigenous health policy but personal and organizational factors can also override this inclination.
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While professional education in medicine and nursing in Australia has been implementing strategies to increase accessibility for Indigenous Australians, allied health professions remain underdeveloped in this area. Failure to improve the engagement of allied health professions with Indigenous Australians, and failure to increase the numbers of Indigenous staff and students risks perpetuating health inequities, intergenerational disadvantage, and threatens the integrity of professions who have publically committed to achieving cultural safety and health equity between Indigenous and non-Indigenous people. Knowing this, leaders in the allied health professions are asking “What needs to change?” This paper presents a critical reflection on experiences of a university-based Indigenous Health Unit leading the embedding of Indigenous perspectives in allied health curriculum, informed by Indigenous community connections, literature reviews, and research in the context of an emerging community of practice on Indigenous health education. Key themes from reflections are presented in this paper, identifying barriers as well as enablers for change, which include Indigenous community relationship building, education of staff and students, and collaborative research and teaching on Indigenous Peoples’ allied health needs and models of care. These enablers are inherently anti-racism strategies that redress negative stereotypes perpetuated about Indigenous Australians and encourage the promotion of valuable Indigenous knowledges, principles, and practices as strategies that may also help meet the health needs of the general community.
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Background Australian Aboriginal and Torres Strait Islander health professionals often juggle the challenges of working and living in the same community in ways that are positive for both themselves and their clients. This study specifically examines the strategies Aboriginal and Torres Strait Islander health professionals have developed to enable them to feel empowered by the sense of being always visible or perceived as being always available. Findings provide examples of how participants (Team Members) established a seamless working self, including how they often held different perspectives to many work colleagues, how Team Members were always visible to community and how Team Members were comfortable to be seen as working when not at work. Methods This qualitative study engages an Indigenous research methodology and uses an Indigenous method, PhotoYarning, to explore lived experiences of a group ( n = 15) of Aboriginal and Torres Strait Islander health workers as they worked in the Australian health sector. Results The analysis presented here comes from data generated through PhotoYarning sessions. Team Members in this study all work in health care settings in the communities in which they also live, they manage an extremely complex network of interactions and relationships in their daily working lives. They occupy an ambivalent, and sometimes ambiguous, position as representing both their health profession and their community. This article explores examples of what working with seamlessness involved, with findings citing four main themes: (1) Being fellow members of their cultural community, (2) the feeling of always being visible to community as a health worker, (3) the feeling of always being available as a health worker to community even when not at work and (4) the need to set an example. Conclusions While creating the seamlessness of working and living in the same community was not easy, Team Members considered it an important feature of the work they did and vital if they were to be able to provide quality health service to their community. However, they reported that the seamless working self was at odds with the way many of their non-Indigenous Australian colleagues worked and it was not well understood.
Indigenous peoples in Australia and similar colonised countries are subject to racism and systemic socioeconomic disadvantages, resulting in worse health outcomes compared to non‐Indigenous counterparts. Such inequities persist despite governments’ attempts to reduce them. Since 2008, Australian governments have committed to a national ‘Closing the Gap’ (CTG) to reduce inequities in health, education, and employment outcomes between Aboriginal and Torres Strait Islander peoples and other Australians, but with limited success. We applied policy theory and a cultural safety framework developed for the research to analyse stakeholder perceptions of CTG policy implementation between 2008 and 2019. We identified policy‐shaping ideas and policy incoherence in the environment surrounding CTG policy that obstructed culturally safe policy. Top‐down, prescriptive modes of implementation were also a barrier. However, Indigenous‐led policy partnerships and community‐controlled services in the health sector have met principles of cultural safety. Identifying these strengths and weaknesses points to ways in which implementation of CTG policies can be improved to achieve cultural safety and reduce Indigenous health inequities. These results may hold lessons for similar countries such as the United States, New Zealand, and Canada. We applied policy theory and a cultural safety framework to investigate stakeholder views of the implementation of Australia's ‘Closing the Gap’ (CTG) Indigenous health policies, circa 2008–2019. The paper identifies strengths and weaknesses of CTG and identifies key areas of policy reform to advance cultural safety and improve Indigenous health.
Indigenous employment is a key point of engagement between Indigenous people and mining companies. Over the past two decades, research shows that the Australian mining industry has increased the numbers of Indigenous employees within the mining workforce. However, less is known about how well the industry is retaining Indigenous employees and what factors support retention. This article begins to fill this gap by presenting outcomes of qualitative research undertaken with both former and current Indigenous employees of a major employer of Indigenous people in the Pilbara region of Western Australia. We elucidate the main reasons for turnover intention as articulated by Indigenous employees and examine the strategies available to mining companies to address voluntary turnover within this cohort. The findings suggest that a culturally competent non-Indigenous workforce, culturally appropriate support mechanisms and access to professional development opportunities are key retention factors. The paper concludes by arguing that the mining industry will need to focus both on ensuring a culturally safe workplace for its Indigenous employees, and on increasing the regional Indigenous labour pool, if it is to contribute to more sustainable outcomes.