Introduction

Australian Aboriginal and Torres Strait Islander people, hereafter referred to respectfully as Indigenous people, comprise just over three percent of the Australian population. The Australian Indigenous population is diverse with at least 167 traditional languages spoken in homes [1]. Australian health care professionals must acknowledge and respect this diversity and the health care needs of this population. The effects of colonisation have resulted in this population carrying a disease burden of 2.3 times that of non-Indigenous Australians [2]. Consequently, the Australian medical workforce must develop and deliver culturally safe care to improve access to healthcare for Indigenous people and address this health inequity [2].

Cultural safety is a key priority for improving the health care of Indigenous peoples. The teaching of cultural safety has been complicated by the wide variety of different terms and definitions in use [3]. However, in 2019, a consensus definition was released by the Australian Health Practitioner Regulation Agency (AHPRA) Aboriginal and Torres Strait Islander Health Strategy group. This definition was unique in having been derived in consultation with Aboriginal and Torres Strait Islander community. This definition now provides a consistent basis for teaching and learning cultural safety, as below:

“Cultural safety is determined by Aboriginal and Torres Strait Islander individuals, families and communities. Culturally safe practice is ongoing critical reflection of health practitioner knowledge, skills, attitudes, practicing [sic] behaviors and power differentials in delivering safe, accessible and responsive healthcare free of racism” [4].

In Australia, primary care is largely provided through private general practices which ideally provide comprehensive, holistic, person-centred, and continuous care to patients [5]. The medical workforce in general practice consists of specialist general practitioners (GPs), non-specialist GPs and GPs in training (hereafter referred to as registrars). Registrars train to be specialised GPs under an apprenticeship model in both the hospital and community setting [6] and have core curricula requirements for demonstration of cultural safety [5,7].

The mechanisms whereby registrars develop cultural safety in Indigenous health are poorly understood. A 2016 integrative review of the literature on developing cultural competence in general practice reported on eight studies in Indigenous health [8]. None of these studies explored how GP registrars perceive they develop cultural safety or similar. Given the link between cultural safety and improving health of Indigenous Australians, it is important to understand the development of skills in this domain amongst learners who will become a considerable component of the workforce into the future.

This project seeks to explore how Queensland GP registrars perceive they develop towards cultural safety in readiness to consult with Indigenous patients.

Methods

Results

Participant characteristics

Sixteen registrars participated in this study. A further ten registrars indicated willingness to be interviewed but did not respond to a follow-up email to schedule an interview time. As data analysis suggested no new insights were being generated and thematic saturation had been reached after sixteen interviews, further attempts at contact were not made.

Overall, the registrar sample was comparable to the training cohort except with over-representation of junior doctors and under-representation of international graduates. Trainees from both Australian general practice training colleges were equally represented. Two participants identified as Aboriginal and Torres Strait Islander. Participant characteristics are detailed in Table 1.

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Table 1. Participant characteristics.

https://doi.org/10.1371/journal.pone.0325960.t001

Registrars described four main factors that contribute to their development of cultural safety (Fig 1).

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Fig 1. Factors that contribute to the development of cultural safety.

https://doi.org/10.1371/journal.pone.0325960.g001

Shared/similar life experience

Many registrars described the development of cultural safety through shared or similar experiences with Indigenous peoples (Table 2). These included both deficit and strengths-based experiences.

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Table 2. Shared and similar life experiences.

https://doi.org/10.1371/journal.pone.0325960.t002

1.Cultural safety (or similar) training.

All registrars had completed cultural safety training (or similar) as part of their university studies, hospital employment or GP training. These ranged from on-line modules, to 2–3-hour workshops to 1–2-day masterclasses with cultural immersions. Most registrars described the educational experience as positive, particularly if it was delivered with local context.

I found they were good if they were locally run and they were about my local area that I was working in or being in, but otherwise some of them it’s not very transferrable. [7400)

Notably, not all cultural training was a positive experience. One registrar described feeling distressed by formal cultural safety training. This distress was not related to grappling with the injustice of past wrongs or ongoing health inequalities. On one occasion, this registrar was upset by the unfairness of a simulated, constructed consultation not adequately reflecting his own experience with Indigenous people. Another time this registrar struggled with the tone of delivery of a workshop and not knowing how to process the emotion expressed by the speaker.

I went to a med school with a lot of people of different coloured skins. And we were doing sort of a cultural safety workshop in general practice, and it just felt like we were being yelled at the whole time... and we all sort of commented at the end, “Well, where do you go with that?” …. The overwhelming sense is that just sit there and shut up and wait for it to go through because if you say anything then you’ll be labelled with the ‘R’ [Racist] word and which is like the death of you, like professionally. (6389)

Learning the history of Indigenous people was the most frequently reported outcome of cultural safety training. Registrars also described learning about the epidemiology of disease, attitudes and particular practising behaviours and skills. Fig 2 presents a summary of registrar learnings, and these are detailed in Table 3.

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Table 3. Learnings from cultural competency (or similar) training.

https://doi.org/10.1371/journal.pone.0325960.t003

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Fig 2. Summary of registrars’ main learnings from formal cultural safety training.

https://doi.org/10.1371/journal.pone.0325960.g002

2. Experiential learning.

Most registrars described interacting with Indigenous people, and people from other cultures, as the most effective way to develop cultural safety.

But I think it’s just something that you kind of have to learn as you go. (1131)

And things start to become more natural when we talk about cultural safety and practice cultural safety. It goes from this sort of contrived, theoretical thing they sort of taught you in med schools…and then it slowly trickles and translates into actual real-world practice, which also has to grow and develop alongside all the other skills. Like at one point when I put in a cannula as a med student, I was like shaking. And now I do it without even thinking. It’s all these skills that unfold with you thinking about it less and less. (6389)

Registrars described the value of learning from patients whilst on clinical placements as students and then further as junior doctors. Nearly half of the registrars described it as acceptable and appropriate for patients to educate, teach or correct culturally unsafe care.

I think asking patients directly, “Is there anything that I say or do that has offended you or is there something in this process that might make you feel like you’ve been violated or harmed?”. (3270)

Just asking the patients in particular, especially with Aboriginal and Torres Strait Islander patients, because I’m completely ignorant or I still am quite ignorant, but was even more so just when I ask things be saying, say, sort of be like, oh, “I’m not sure and I’m really sorry if this comes across as racist, but can I ask this or is it racist of me to ask this? Or is it racist for me to say this?” And just asking them if it’s culturally appropriate, I guess, …or even asking them, is it culturally appropriate for me to be talking to you about this as a woman doctor, especially with men? Yeah. So, I think just asking because I think people are quite responsive to that and they’re always more than happy to give feedback and teach. (1131)

Some registrars were concerned about asking questions about culture and cultural safety out of fear of this being perceived as racist behaviour.

And if they said something that is not consistent with the mainstream culture, I would just confirm with them. For example, like maybe they have different beliefs regarding death. I would just ask them, “Can you elaborate? Can you tell me more about your understanding, your beliefs about death, and what is the normal thing to do?” For example, if the mom is dying from a terminal illness, what’s the correct culturally thing to do? (7358)

So, if they wanted to explore a concept that wasn’t something that I’m familiar with, I would just ask the: “I don’t know exactly what that means to you. Can you help me and teach me what it means and how you want me to take that further into the consultation?” (7216)

Other registrars expressed a more proactive approach to providing culturally safe care in asking patients or Aboriginal Liaison Officers about their opinions and experiences.

So, when I moved there, I really didn’t know much about the culture but quickly picked up the ropes and a lot of it was learning from either the liaison officers or from the patients themselves and their family members. (6278)

No registrars directly mentioned the leadership or expertise of cultural educators or cultural mentors. One registrar noted learning local history from their GP supervisor (1111). Another described learning from historical Australian drama films (3270).

3. Critical reflection.

A registrar expressed the importance of ongoing critical reflection in the development of cultural safety:

I think the most effective way has been experience, but then also reflection…on situations where it doesn’t go right, where the patient does express they’re unhappy or they haven’t gone ahead with something that you wanted them to. And then working out the reasons why. Was because it was in conflict with some of their beliefs or their cultural practices? And so, then that led to I need to know a little bit more about this person, but also a little bit more about that culture or religion or ethnicity or something that’s happened there (7400).

An Indigenous registrar detailed their own experiences of feeling culturally unsafe in the work environment and how they drive non-Indigenous doctors to self-reflect.

So, a lot of my [Indigenous] colleagues that have felt culturally unsafe, we have been adapting to how could we politely reword or ask for an explanation [from non-Indigenous doctors]? …So, in those circumstances I’ve said, “Oh, it’s very interesting that you say that”. When I had a colleague ask me what percent of Aboriginality I was, I said, “It’s very interesting that you ask that and if I had given you any particular number, would that change your opinion of me? If I was to say 5%, 25%, 33% or 100%? What value do you give that number? So, I’m interested to ask you why you’ve asked that particular question?” So, I think over time to develop cultural safety is to adapt to the environments and to learn to politely question why someone is asking you something that you may feel threatened, that you don’t feel culturally safe in that environment. (8230)

Discussion

This study explored how GP registrars perceive that they developed towards cultural safety. Registrars described the development of cultural safety through shared or similar life experience, cultural safety training, experiential learning, and reflective practice.

By nature of being a qualified medical practitioner, registrars are in a position of relative privilege through both socioeconomic and healthcare access. Registrars may not readily recognise this advantage and the implications of this position. Some registrars in this study had identifiers that simultaneously granted them both power and marginalisation within the Australian context [12]. Over half of the registrars in this study were born outside of Australia. As such, these registrars may not feel assimilated into the dominant culture. Furthermore, registrars work as junior doctors in a hierarchical structure and earn less than the average weekly ordinary time earnings for full-time adults [13]. These factors may influence the lens through which registrars view privilege and the social determinants of health and may pose a barrier to culturally safe care. Rather than pretending these sociocultural differences do not exist, Wilson et al [14] suggest reframing how these differences shape the patient-registrar consultation leading to improved outcomes. In contrast, registrars who feel they do not have shared commonality with Indigenous peoples, or recognise they benefit from social privilege, must not presume they are incapable of relating to Indigenous patients.

Registrars described key learnings of knowledge, attitude, practising behaviours and skills from formal cultural safety training. These learnings are commonly classified as cultural awareness training and has been the focus for most health professional training within Australia [15]. Registrars mentioned the importance of Aboriginal Liaison Officers in the development of cultural safety. Previous studies have also shown the benefit of cultural educators and cultural mentors in teaching about culture, history, and their impact on patients [16,17] however no registrars directly discussed their influence. This may reflect that registrars did not recognise cultural mentors or cultural educators who were delivering training. Alternatively, it may indicate that most registrars, particularly those not working within Aboriginal Medical Services, have limited access to cultural educators and cultural mentors. Universal access to cultural educators and cultural mentors may assist in improving development of cultural safety by GP registrars.

Most registrars described exposure to, and working with, Indigenous peoples as being fundamental to their development of cultural safety. Furthermore, registrars had an expectation that patients would be prepared to both teach cultural safety and correct any culturally unsafe behaviour observed amongst clinicians. Registrars did not always seem to engage in critical self-reflection to recognise the danger of culturally unsafe behaviour on patients (or Indigenous colleagues) or the effect of their own position of power within this relationship. Finding ways to enable the patient to determine culturally safe care, but not be responsible for teaching or correcting, is a challenge for health education system. We assert that it is inexcusable to expose patients to culturally unsafe care within the learning process. While people need to learn they should not do so in an unsafe way that may impact others. Patients have a right to feel safe; this study suggests we may be exposing patients to unsafe learners, who may put them at risk. Thus, a well-meaning educational approach – providing registrars with experience and exposure to Indigenous health – may in fact be detrimental to those it is trying to help. This ‘hidden’ problem may contribute to the health inequity gap and have wider impacts for training as well as accreditation and supervision.

Some registrars recognised the cultural burden and inherent risks of expecting patients to teach and remediate unsafe behaviours and instead chose not to ask questions. By defaulting to a place of their own safety rather than seeking out learnings from supervisors or other appropriate role models, registrars may have missed opportunities to develop cultural safety skills. Similarly, the registrar with a negative experience of cultural safety training may have adopted “ad hoc coping behaviours” rather than adopting a self-reflective stance and focussing on how cultural identity is complex and unique to every individual [8 p7].

Registrars did not report learning that cultural safety must be determined by Indigenous peoples, or the importance of critical reflection. The registrars in this study had completed medical degrees from varying universities across Australia and have undertaken cultural safety training. Teaching and education on this fundamental basis of cultural safety appears not to influence registrars’ perception of cultural safety. Making the invisible racism visible, whilst protecting patients from culturally unsafe care, requires an approach that does not tolerate any interpersonal or systemic racism [18]. Supporting registrars to understand their own cultural lens and examine the influence of their own culture on consultations may assist development and delivery of culturally safe care.

Conclusion

Cultural safety is a lifelong learning journey balancing critical self-reflection against an external determination of cultural safety. Understanding this process warrants further research and review of medical education teaching. There is need for further evaluations of cultural safety in GP training considering how cultural safety is both taught and assessed: who determines what is culturally safe care and what are the attributes of the GP registrar, as determined by the Indigenous community, that contribute to a culturally safe practitioner. Culturally safe health care will play an important role in redressing health inequities amongst Indigenous people. Understanding the development of cultural safety amongst learners is an important step towards supporting the development of a culturally safe primary health care workforce.