Beyond 2020: Addressing racism through transformative Indigenous health and cultural safety education

We acknowledge the sovereignty of Indigenous Peoples across the Earth as the traditional custodians of Country and respect their continuing connection to culture, community, land, waters, and sky. We pay our respect to Elders past and present and in particu- lar to those who led the way, allowing us to realize our own aspirations to be healers and carers, ushering our people from and to the Dreaming.

The 2020 International Year of the Nurse and Midwife has harshly revealed the need to increase the nursing and midwifery workforce and for the disciplines to invest in anti-racism initiatives. The World Health Organization (WHO) (2020) has called for a marked increase in the numbers of nurses and midwives, academics and students. However, to ensure the cultural safety of patients and staff, WHO (2020) stated this increase in workforce must include clinicians and ed- ucators from underrepresented populations, in particular Indigenous populations. Stemming from our experiences as First Nations nurses, midwives, practitioners, researchers, educators and allies, this editorial outlines our agenda to reform Indigenous health and cultural safety curricula in Australian higher education institutions.

This year has revealed stark inequities in the response to COVID- 19, with Indigenous Peoples disproportionally affected across the globe (Pilecco et al., 2020; Power, Wilson, et al., 2020). In Australia, as elsewhere, there has also been a huge public response to the international Black Lives Matter protests. The Black Lives Matter movement condemns Black deaths in custody and the entrenched systematic racism that allows it to continue. In Australia, it resonated with the Aboriginal deaths in custody movement and prompted a call for action among Australian nursing and midwifery leaders to transform curricula to ensure the workforce had the necessary skills, knowledge and attributes to address systematic racism (Geia et al., 2020) and through this action address one of the greatest barriers to increasing the numbers of Aboriginal and Torres Strait Islander Nurses and Midwives (West, 2012).

Australian Bachelor of Nursing (BN) and Bachelor of Midwifery (BM) accreditation stipulates a discrete subject focusing on Aboriginal and Torres Strait Islander Peoples’ history, culture and health as well as further content being scaffolded throughout the programmes (ANMAC, 2014, 2019). Currently, content in the BN curriculum should be based on the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) Nursing and Midwifery Aboriginal and Torres Strait Islander Health Curriculum Framework (ANMAC, 2019) and it is expected that the next iteration of the BM accreditation standards will follow suite.

A recent review of one Australian university’s BN curriculum con- cluded that it is possible to satisfy the accreditation standards with- out providing students with a cohesive programme of Indigenous health content (Zimmerman et al., 2019). There is a great need to invest in developing evidence on best-practice approaches to opti- mising Aboriginal and Torres Strait Islander health education in nurs- ing and midwifery programmes, in addition to measuring impact on patient outcomes; these are current limitations (Power et al., 2016). Additionally, research with non-Indigenous nursing academics about their ability to teach Aboriginal and Torres Strait Islander Health and cultural safety to undergraduate nursing students revealed that they were not confident in this skill and needed to ‘step-up’ (Doran et al., 2019). These findings are concerning because teaching nurs- ing and midwifery students about cultural safety and increasing the Indigenous nursing and midwifery workforce are pivotal strategies for improving Indigenous health outcomes (Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM), 2017; Stuart, 2017).

A limitation of the current discourse regarding these accredita- tion standards is the relationship between the inclusion of Aboriginal and Torres Strait Islander health curricula and the cultural safety of Aboriginal and Torres Strait Islander nursing and midwifery stu- dents and academics. Racism impacts on the success of Aboriginal and Torres Strait Islander students and creates a situation where the student has to decide whether to ignore it, or speak up, often at risk of being further marginalised (Gorman, 2017). Thus, it is no surprise that racism is a factor to students withdrawing from their programme (West, 2012).

In their recent call to action, Geia et al. (2020) outlined four prin- ciples needed to enact transformation throughout nursing and mid- wifery curricula. First, recognition that every Australian nurse and midwife has a role in addressing the health inequities that confine Indigenous health outcomes. Second, drawing on Indigenous ped- agogies and research standpoints, Indigenous nurses and midwives must lead the reform of nursing and midwifery curricula and the flow on effect to the health system. This would enable Indigenous nursing and midwifery academics to safely weave Indigenous knowl- edges and perspectives into teaching and learning approaches and curricula content (Drummond, 2020). Third, nursing and midwifery curriculum must include cultural safety and its association with pro- fessional and institutional racism to be able to address the cultural

and social determinants of Indigenous Peoples. Lastly, Geia et al. (2020) highlight the paradox and tensions inherent in the ‘us and them’ paradigm in the nursing and midwifery professions, referring to the need to transcend the traditional binaries of Indigenous and non-Indigenous nurses, midwives, researchers and educators and hi- erarchies that create tension between. Geia (2020) later clarified this last point referring to the ‘double edged sword’ where both non-In- digenous and Indigenous educators and health professionals needed to examine their own biases in their collaborations with colleagues.

Aboriginal and Torres Strait Islander nursing and midwifery academics are tasked with the often-isolated responsibility of legitimising critical approaches, like cultural safety, in Aboriginal and Torres Strait Islander health education within their respective schools, as well as the inclusion of Indigenous perspectives within nursing and midwifery curricula (Drummond, 2020). Inherent in this work is a requirement for Aboriginal and Torres Strait Islander nursing and midwifery academics to constantly address the institutional and interpersonal racism that continues to devalue and inhibit the success of this work; this is part of the invisible work that is often not realised by others (Drummond, 2020).

By providing opportunities for Indigenous nursing and midwifery academics to develop professionally into leadership positions, uni- versities would enhance the facilitation of this much needed transfor- mation in nursing and midwifery education. For example, by creating specific Indigenous nursing leadership positions in every nursing and midwifery school, universities could contribute significantly to advancing the Indigenous nursing and midwifery portfolios, and ulti- mately improving higher education outcomes for Indigenous nursing and midwifery students (Stuart, 2017). Seeding the health system with graduates who are culturally safe for Indigenous Peoples will lead to better health outcomes overall (Power et al., 2020). To build stronger, coherent research addressing racism in the healthcare sys- tem nationally, Indigenous nursing and midwifery academic staff also need to be supported to network with other Indigenous nursing and midwifery educational researchers (Stuart, 2017).

Transforming nursing and midwifery curricula to produce cultur- ally safe non-Indigenous and Indigenous graduates can be accom- plished through engaging at a national level with peak organisations positioned to enact practical and authoritative change. In a united and collective effort to enact change, we have established a con- sortium of First Nations influencers, practitioners, nurses, midwives and allies to provide leadership and strategic direction for reform in nursing and midwifery education and to address significant gaps in evidence relating to the cultural safety of nursing and midwifery teaching and learning. We will provide direction, guidance and ad- vice regarding the embedding of cultural safety within nursing and midwifery programmes as a way to ensure that curriculum meets the requirements of professional standards. As a consortium, we rec- ognise the critical role of educators in determining Aboriginal and Torres Strait Islander health outcomes and our goal is to address in- stitutional and interpersonal racism in the health system through the transformation of Aboriginal and Torres Strait Islander health and cultural safety education in Australia. By identifying, consolidating and undertaking research guided by the principles of Indigenist re- search and by being a united voice, our aim is to transform the quality of nursing and midwifery care for Indigenous Australians together.

There is increasing recognition of the impact that a unified and culturally safe nursing and midwifery workforce could potentially have in eliminating systematic racism in health systems across the world. The 27.9 million nurses across the globe represent 59% of the health workforce (WHO, 2020). In 2020, there are 325,720 reg- istered nurses and 6251 registered midwives working in Australia (Nursing & Midwifery Board of Australia, 2020) representing nearly 60% of the health workforce (Australian Institute of Health & Welfare, 2020). Most of these nurses and midwives hold a nurs- ing and/or midwifery degree. By ensuring all Australian nursing and midwifery degrees produce culturally safe nurses and midwives, who through truth telling understand the true history of Australia and how the success of the nation-state is inextricably linked to the marginalisation, dispossession, and inequitable health outcomes in Indigenous Peoples, the Australian Health system can be trans- formed for all through sheer strength in numbers.

To ensure curricula is inclusive of truth telling and Indigenous ways of knowing, being and doing across course content and to en- able educators and students to meet objectives of achieving health equity for Indigenous people, the dominant cultural paradigms in nursing and midwifery curricula development must be challenged (Drummond, 2020; Geia et al., 2020; West, 2012). It is imperative that all involved in teaching Indigenous health content are knowl- edgeable, skilled and confident in their understanding and applica- tion of Indigenous health content in nursing and midwifery curricula (Geia et al., 2020).

In enacting this work, we have partnered with CATSINaM to ensure truth telling, the impacts of racism and Indigenous ways of knowing, being and doing are embedded in curricula reform and grounded in relevant, credible and useful evidence. As a collective of Indigenous nursing and midwifery practitioners, educators, re- searchers and allies who share a common goal, to ensure culturally safe care for Aboriginal and Torres Strait Islander Peoples, the con- sortium we have established will conduct research and strengthen evidence in order to challenge, provide direction, guidance and ad- vice about how Indigenous Health and cultural safety is best pro- vided within nursing and midwifery programmes. In doing this, we aim to ensure that curriculum meets the requirements of programme standards, professional standards, and codes.

A culturally safe approach to nursing and midwifery care de- mands the practice of lifelong learning and self-reflectivity. For Aboriginal and Torres Strait Islander nurses and midwives, this can additionally involve self-determined agendas and responsibilities to provide a better and stronger future for our families, communities and peoples (Nakata, 2017). Since many colleagues are still learning about what being culturally safe means and how this is entwined in patient safety standards (AHPRA & National Boards, 2020), trans- formation will necessarily require deep critical reflection on the impacts of settler colonisation and institutional and professional racism in relation to nursing and midwifery care. It will also require praxis to understand and commit to this in practice and ultimately improve quality of nursing and midwifery care. Unlike clinical skills, learning about cultural safety is a deeply personal practice that can assist transform approaches to ‘caring’ within nursing and midwifery professions.

In our commitment to critically reflective, culturally safe prac- tice, beyond 2020 we have chosen to enact our own sovereignty and truth telling (Bennett, 2020) within our inherited Indigenous nursing and midwifery knowledges. We recognise that our own people, Aboriginal and Torres Strait Islander peoples, created the first health systems in Australia, inclusive of midwives, healers and carers (Adams et al., 2018; Carter et al., 1983; NPY Womens Council, 2013). As Aboriginal and Torres Strait Islander nurses and midwives, we continue this ancestral tradition as part of the oldest continuing cultures on the planet (Australian Government, 2017). We stand with those globally who call for truth telling of nurs- ing and midwifery wrongs to Indigenous peoples (Barber, 1999; Brookes & Nuku, 2020; Carey et al., 2020; Moorley et al., 2020; Stake-Doucet, 2020).

Being a nurse or midwife has always been a political act, just as being a First Nations person is a political act. It is with a shared sense of responsibility that we have become agitators for reform and transformation. In a time of change as 2020 has been, the time to im- plement curriculum transformation is now. We are the protectors of our ways of knowing doing and being in health care, and we believe these ways hold a gift for the Australian healthcare system and what it ‘truly means’ to be a nurse and or midwife and to care.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

REFERENCES

Acknowledgement of Country

The Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) acknowledges the Australian Aboriginal and Torres Strait Islander peoples of this Nation.

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