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Cultural safety

Position statement Last updated: Dec 2021 Published in Australia Reference: PS #105

This position statement advocates for universal cultural safety in mental health systems, services, and care.

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has developed this position statement to advocate for universal cultural safety in mental health systems, services, and care for all consumers[a]. What cultural safety looks like is determined by each consumer; the outcome of culturally safe health systems and services is consumers feeling comfortable and secure accessing care.[1] The need for cultural safety in mental health services is best exemplified by the experiences of Aboriginal and Torres Strait Islander peoples in Australia and Māori in Aotearoa/New Zealand, and is also relevant to all people across culturally and linguistically diverse communities, beliefs, values, ethnic groups, religion or faith, age, ability, sexual orientation and gender identity.

A glossary of terms is available at the end of this position statement.

Background

Cultural safety is an outcome of the way that health practitioners’ practice and is crucial in achieving equity for all cultures. The concept of ‘cultural safety’ is an expansion of the earlier ‘cultural competency’, with the differentiation being the recognition of power dynamics.[2] The concept of ‘cultural safety’ in healthcare was first established by Dr. Irihapeti Ramsden and Māori nurses in the 1990s to mean ‘a focus for the delivery of quality care through changes in thinking about power relationships and patients’ rights’.[1, 2] By 1992, cultural safety training was required within New Zealand nursing and midwifery education.[2]

Systemic inequities are present in Australia and New Zealand due to colonisation; socioeconomic and political realities have contributed to discrimination and racism within the health system.[3, 4] Cultural safety is an important principle of reconciliation and the dialogue over any treaty development process. The New Zealand Code of Health and Disability Services Consumers’ Rights states that ‘every consumer has the right to be provided with services that take into account the needs, values, and beliefs of different cultural, religious, social, and ethnic groups, including the needs, values, and beliefs of Māori’.[5]

Key messages

  • Cultural safety underpins achieving equitable health outcomes. This applies to all people across culturally and linguistically diverse communities, beliefs, values, ethnic groups, religion or faith, age, ability, sexual orientation and gender identity.

  • Cultural safety is defined by the consumer accessing care, and they must be involved in decision-making about how their care is delivered.

  • Cultural safety, at an individual level, addresses the power imbalance between the health practitioner and the consumer. Culturally safe practice involves practitioners acknowledging how their own beliefs and biases can influence their practice and the way that consumers receive care. Health practitioners are encouraged to engage in self-reflection and self-awareness in order to achieve productive therapeutic relationships.

  • Culturally safe principles must be embedded within training and Continuing Professional Development (CPD) programs which prepare health practitioners for practice.

  • Cultural safety is about addressing the power structures within health systems and understanding how current health systems uphold the values, attitudes and practices of the dominant culture. Health systems and services must pursue cultural safety and cultural responsiveness as a means to improving the quality and standard of care provided to all consumers.

  • Cultural safety must be prioritised by health systems, organisations and practitioners to eliminate culturally unsafe practices that are detrimental to positive health outcomes. Discrimination and racism persist within the colonial frameworks that shape health services and individual practitioners’ practice.

Cultural safety in healthcare

Cultural safety is a way of practicing that brings benefits to all consumers and communities.[6] It is underpinned by the acknowledgement of all parties that respect for cultural status, age, gender, sexual orientation, ethnicity and spirituality is fundamental to good healthcare.[7] Respect involves the ongoing fostering of shared meaning, shared knowledge and respect for consumer experiences and identity.[8, 9]

Culturally safe practitioners are open to viewing cultural considerations as integral to their practice, and ongoing reflection and learning as necessary to respond appropriately to those in their care.[10] This effort and self-reflection helps to prevent the imposition of the practitioner’s own values and beliefs onto consumers of diverse groups.[11, 12] Culturally responsive practice, as an integral part of cultural safety, places inherent value on the knowledge, skills and perspectives of diverse cultural communities which contribute to health and wellbeing.[13] Cultural safety must also be underpinned by models of care that involve consumers and their family/whānau (b) in decisions about care.[14-16] For more information, please see the RANZCP Professional Practice Guideline: Information sharing with families/whãnau/carers.

Health services should ensure, through codes of conduct, that all engagement adheres to the United Nations Declaration of the Rights of Indigenous Peoples in addition to any relevant national strategies.[17] Particular attention must be paid to the right of self-determination; health services and practitioners must support consumers to participate in decision-making. The Te Tiriti o Waitangi (c) is driving change in New Zealand, with the key principle being Tino Rangatiratangata (d). [18] In Australia, the RANZCP supports the aspirations of the National Agreement of Closing the Gap.[19]

The importance of supporting a culturally safe health workforce is reflected in the Medical Council of New Zealand’s accreditation standards for ‘New Zealand training providers of vocational medical training and recertification programmes’.[20] The Australian Medical Council provides accreditation standards for ‘Primary Medical Education Providers and their Program of Study and Graduate Outcome Statements’ and for ‘Assessment and Accreditation of Specialist Medical Programs and Professional Development Programs’, which both recognise a culturally safe workforce as key.[21, 22]

Cultural safety and psychiatry

Cultural safety is central in the delivery of equitable mental healthcare. The process of practicing in a culturally safe manner involves acknowledging the inherent power imbalance in a relationship between a psychiatrist and a consumer in their care, particularly in high-risk and challenging contexts (e.g. prisons, out of home care, remote communities, aged care).[23-27] Where psychiatrists strive to implement culturally safe practices and regularly reflect on their own practice, they will see improved outcomes for the consumers that they work with and their communities.[28]

Experiencing mental healthcare in a culturally safe environment and in a culturally responsive manner is a human right. Cultural safety must not be viewed as optional in good mental healthcare but as an integrated part of effective care practices. Many psychiatrists have understood this implicitly for some time, but there has too often been instances where ignorance of culture has caused harm and negative outcomes.[29] As many mental health conditions are acutely influenced by cultural relationships, community interactions and past experiences of traumatic events, the need for understanding and skills in this area is crucial to effective mental health and psychiatry practice.[30, 31] 

Religion and/or spirituality may be important across a wide variety of consumers and communities in Australia and New Zealand, including Māori, Pasifika, Aboriginal and Torres Strait Islander peoples and those from multicultural backgrounds. Psychiatrists should acknowledge that matters of religion and/or spirituality are of core relevance to the expression and treatment of mental disorders. For more information, please see the RANZCP Position Statement 96: The relevance of religion and spirituality to psychiatric practice. Mental health systems must also recognise and address the needs of the LGBTIQ+ (e) population.[32] For more information, please see the RANZCP Position Statement 83: Recognising and addressing the mental health needs of the LGBTIQ+ population.

Cultural safety for the workforce

The RANZCP highlights the value of the expertise that culturally and linguistically diverse health practitioners bring to the workforce, including Specialist International Medical Graduates (SIMGs). The health workforce should be representative of the community it serves. To enable this, further work is required to ensure that workplaces are culturally safe; the RANZCP recognises the additional ‘load’ that culturally diverse members of the health workforce bear. This may be additional expectations and demands at work due to cultural identity, such as educating others or other forms of tokenistic treatment.[33, 34] This is referred to as ‘cultural loading’. It is important to recognise cultural loading and provide support for culturally diverse members of the workforce. This may include ‘cultural supervision’, which assists health practitioners to review practices or respond to self-reflections.[35] 

Growing the Aboriginal and Torres Strait Islander health workforce in Australia, including leadership and system governance positions, improves health and care outcomes for Aboriginal and Torres Strait Islander community members.[36] 39% of Aboriginal and Torres Strait Islander employees have reported experiencing cultural loading.[33] In Australia, one danger of this is the homogenisation of the many distinct Aboriginal and Torres Strait Islander cultural groups.[34] These challenges and pressures can result in long working hours, and performing additional duties, and can have mental health impacts.[37]

In some cases, Aboriginal and Torres Strait Islander mental health practitioners may be required to negotiate the dual roles of both family member and service provider.[38] If an employee is also a part of a consumer’s family, or wider cultural group, employers should take steps to ensure the worker receives adequate support.[37, 38] Cultural supervision may assist, and is recommended, for example, when working with Aboriginal and Torres Strait Islander communities, or in workplaces that are not culturally safe.[35] Support should come from a local cultural representative with experience in the practice area. For more information, please see the RANZCP position statement on Aboriginal and Torres Strait Islander mental health workers.

Growing and retaining the Māori health workforce in New Zealand is similarly important.[37, 39, 40] Whakamaua: Māori Health Action Plan 2020-2025 notes that workforce in New Zealand must reflect the Māori population, Māori values and Māori models of practice.[41] The Māori workforce is also critical in ensuring successful implementation of Whānau Ora and the principles of the Te Tiriti o Waitangi (f). [18, 37] It is only by progressing this kaupapa (g) that Māori can experience safe care. Leadership is needed to build capacity and capability within the Māori workforce; the non-Māori workforce must value and understand Māori approaches and work towards supporting the concepts of Whānau Ora.[37] 

Recent reports have highlighted the challenges in developing a Māori medical workforce in order to be responsive to the specific needs of Māori.[42, 43] Barriers to development include members of the workforce experiencing cultural loading and culturally unsafe working environments.[42, 43] For Māori, cultural supervision is an important aspect of cultural safety for the workforce and may act as a support to assist in reducing the impacts experienced from cultural loading.[42, 44] This can also be for anyone working with Māori, or Māori working with other cultures.[44]

Towards cultural fluency

The RANZCP highlights that the goal of achieving culturally safe practice for all consumers, including family/whānau or carers, is an ongoing process. To support this, a culturally fluent health workforce is required. Cultural fluency refers to the ability of health practitioners to work across diverse environments with agility in a way that corresponds to changing practice across contexts.[45] In order to achieve this, it is important to make progress on embedding cultural safety within systems and services. Therefore, cultural safety outcomes should be monitored and reported on including health workforce outcomes, recruitment and retention.[2] In Australia, this may involve an Aboriginal and Torres Strait Islander health and workforce strategy at a service level.[46] In New Zealand, Whakamaua provides an action plan to address workforce issues in both the short-term and long-term.[41]

Recommendations

The RANZCP recommends that:

  • Cultural safety principles, procedures and practices are acknowledged and enacted to ensure that all consumers have access to effective, culturally secure mental healthcare or services.[2]
  • Culturally diverse consumers and their needs are routinely incorporated into mental health systems and processes, including recruitment within the care workforce and leadership positions, service funding, and hospital and health service design.[37, 39, 40, 46, 47]
  • Culturally safe practice is prioritised by individual health practitioners, including psychiatrists and those in psychiatry training to ensure that consumers receive care that is culturally safe, maximises recovery potential, and minimises the risk of inflicting harm or negative outcomes for consumers, family/whānau, carers and staff.

    Consideration of culturally safe practice and health equity should be part of every psychiatrist’s continuing professional development activities.
  • Cultural supervision is provided by health services for health practitioners to engage in. Cultural supervisors should be cultural representatives with experience in the practice area.

  • Culturally safe practice is endorsed by health services through codes of conduct and the use of health practitioner training and education and supervision to build knowledge and understanding.[2, 47]

  • Culturally diverse members of the health workforce are provided with support, and the cultural load is recognised.[33, 37, 40, 42]

  • Cultural safety outcomes are monitored and reported on including health workforce outcomes, recruitment and retention.[2]

Additional resources

On cultural safety

Australia

New Zealand

Footnotes

(a) The term ‘consumer’ is used for clarity and consistency in this document, although it is recognised that individuals may prefer alternative terms, for example person, patient, client or service user.

(b) Whānau’ (pronunciation: fa:no) - A Māori word that can be used to describe an extended family group spanning three to four generations. The whānau continues to form the basic unit of Māori society (Rāwiri Taonui).

(c) Te Tiriti o Waitangi or the Treaty of Waitangi is Aotearoa’s founding document outlining how Māori and the British Crown work together in partnership.

(d) Tino Rangatiratangata – self-determination

(e) LGBTIQ+ - refers collectively to people who are lesbian, gay, bisexual, trans, intersex, ‘queer’ or ‘questioning’ (exploring their orientation and identity), as well as people with alternative sexual, orientation, or sex or gender identities who do not identify with the other terms.

(f) Te Tiriti o Waitangi or the Treaty of Waitangi is Aotearoa’s founding document outlining how Māori and the British Crown work together in partnership.

[g] Kaupapa – agenda.

Glossary

Cultural competency

Cultural competency has been a recognised approach to improving access to healthcare to culturally diverse groups for the purpose of reducing health disparities.[2] Core concepts include awareness, respect and sensitivity.[3]

Cultural safety

Cultural safety builds upon the concept of cultural competence. It differs in the emphasis on analysing systemic barriers to safe care, such as power dynamics.[3] The RANZCP supports the definitions:

  • Australian Health Practitioners Regulation Agency definition: ‘Cultural safety is determined by Aboriginal and Torres Strait Islander individuals, families and communities. Culturally safe practice is the ongoing critical reflection of health practitioner knowledge, skills, attitudes, practising behaviours and power differentials in delivering safe, accessible and responsive healthcare free of racism’.[4, 48]
  • Medical Council of New Zealand definition: ‘The need for doctors to examine themselves and the potential impact of their own culture on clinical interactions and healthcare service delivery. The commitment by individual doctors to acknowledge and address any of their own biases, attitudes, assumptions, stereotypes, prejudices, structures and characteristics that may affect the quality of care provided. The awareness that cultural safety encompasses a critical consciousness where healthcare professionals and healthcare organisations engage in ongoing self-reflection and self-awareness and hold themselves accountable for providing culturally safe care, as defined by the consumer and their communities’.[7]

Cultural fluency

Cultural fluency extends towards a fuller understanding of the environment and how the dominant cultural values and norms are often viewed as ‘neutral’, and those belonging to the dominant culture may perceive themselves as ‘culturally objective’.[49] Cultural fluency refers to the ability to work across diverse environments with agility in way that corresponds to changing practice across contexts.[45]

Cultural intelligence

Cultural intelligence is a related concept, referring to the skill of managing cultural differences or working across cultures/in a multicultural environment; this particularly refers to a workplace context.[50, 51]

Cultural loading

Cultural loading refers to the cultural load that culturally diverse members of the health workforce bear. This may be additional expectations and demands at work due to cultural identity, such as educating others or forms of tokenistic treatment. [33, 34]

Cultural supervision

Cultural supervision is a tool that assists health practitioners to engage in culturally safe practice by reviewing practices or respond to self-reflections.[35] This is recommended, for example, when working with Aboriginal and Torres Strait Islander communities, or in workplaces that are not culturally safe.[35] Support should come from a local cultural representative with experience in the practice area. For Māori, cultural supervision is an important aspect of cultural safety for the workforce and may act as a support to assist in reducing the impacts experienced from cultural loading.[42, 44] This can also be for anyone working with Māori, or Māori working with other cultures.[44]

Cultural brokerage

Cultural brokerage refers to ‘the act of bridging, linking or mediating between groups or persons of differing cultural backgrounds for the purpose of reducing conflict or producing change’.[52, 53]

Cultural responsiveness

Cultural responsiveness is an integral part of cultural safety and places inherent value on the knowledge, skills and perspectives of diverse cultural communities that contribute to health and wellbeing.[13]

Cultural governance

Cultural governance refers to systems of governance that cultural groups or societies construct for decision-making, determining roles and accountability, and developing processes for interacting with social and economic structures.[54, 55] Systems of governance differ between cultures and change over time.[55]

Responsible committee: Practice, Policy and Partnerships Executive Committee 

References

1. Cultural Safety and Nursing Education in Aotearoa and Te Waipounamu: Irihapeti Merenia Ramsden; 2002 [Available from: https://www.croakey.org/wp-content/uploads/2017/08/RAMSDEN-I-Cultural-Safety_Full.pdf.]

2. Elana Curtis RJ, David Tipene-Leach, Curtis Walker, Belinda Loring, Sarah-Jane Paine & Papaarangi Reid Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. International Journal for Equity in Health volume. 2019;18(174).

3. Curtis E, Jones R, Tipene-Leach D, Walker C, Loring B, Paine S-J, et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. International Journal for Equity in Health. 2019;18(1):174.

4. Tyson SY. Can cultural competence be achieved without attending to racism? Issues in Mental Health Nursing. 2007;28(12):1341-4.

5. Commissioner. NHaD. Health and Disability Commissioner (Code of Health and Disability Services Consumers' Rights) Regulations; 1996.

6. Truong M, Paradies Y, Priest N. Interventions to improve cultural competency in healthcare: a systematic review of reviews. BMC Health Services Research. 2014;14(1):99.

7. MCNZ. Statement on Cultural Safety; 2019.

8. Williams R. Cultural safety – what does it mean for our work practice? . Australian and New Zealand Journal of Public Health. 1999;23(2), 213-214.

9. AHMAC. National Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2016-2026; 2015.

10. Lacey C, Huria T, Beckert L, Gilles M, Pitama S. The Hui Process: a framework to enhance the doctor-patient relationship with Māori. N Z Med J. 2011;124(1347):72-8.

11. Askew DA, Jennings WJ, Hayman NE, Schluter PJ, Spurling GK. Knowing our patients: a cross-sectional study of adult patients attending an urban Aboriginal and Torres Strait Islander primary healthcare service. Australian Journal of Primary Health. 2019;25(5):449-56.

12. Statement on cultural safety: Medical Council of New Zealand; 2019 [Available from: https://www.mcnz.org.nz/assets/standards/b71d139dca/Statement-on-cultural-safety.pdf]

13. Australia IAH. Cultural Responsiveness Framework 2015 [Available from: https://iaha.com.au/workforce-support/training-and-development/cultural-responsiveness-in-action-training/]

14. Curtis E. Indigenous Positioning in Health Research: The importance of Kaupapa Māori theory-informed practice. AlterNative: An International Journal of Indigenous Peoples. 2016;12(4):396-410.

15. Hicks KA. Cultural Competence: Facilitating Indigenous Voices Within Health Promotion Competencies. SAGE Open. 2018;8(2):2158244018783218.

16. Bobba S. The central concept of empowerment in Indigenous health and wellbeing. Australian Journal of Primary Health. 2019;25(5):387-8.

17. Declaration of the Rights of Indigenous Peoples: United Nations 2007 [Available from: https://www.un.org/development/desa/indigenouspeoples/declaration-on-the-rights-of-indigenous-peoples.html]

18. Treaty Of Waitangi: New Zealand History;  [Available from: https://nzhistory.govt.nz/politics/treaty/read-the-treaty/english-text]

19. National Agreement on Closing the Gap: Joint Council on Closing the Gap; 2020 [Available from: https://www.closingthegap.gov.au/]

20. Accreditation standards for New Zealand training providers of vocational medical training and recertification programmes: Medical Council of New Zealand;  [Available from: https://www.mcnz.org.nz/assets/standards/Guidelines/3aca58ba46/Accreditation-standards-for-New-Zealand-training-providers-of-vocational-medical-training-and-recertification-programmes.pdf]

21. Accreditation Standards for Primary Medical Education Providers and their Program of Study and Graduate Outcome Statements. Australian Medical Council [Available from: https://www.medicalboard.gov.au/Accreditation/Medical-schools.aspx]

22. Accreditation of specialist medical colleges and their programs of study: Australian Medical Council; 2015 [Available from: https://www.medicalboard.gov.au/Accreditation/Specialist-medical-colleges.aspx]

23. McEldowney R, Connor MJ. Cultural Safety as an Ethic of Care: A Praxiological Process. Journal of Transcultural Nursing. 2011;22(4):342-9.

24. Heffernan EB, Andersen KC, Dev A, Kinner S. Prevalence of mental illness among Aboriginal and Torres Strait Islander people in Queensland prisons. Medical Journal of Australia. 2012;197(1):37-41.

25. Indig D. Comorbid substance use disorders and mental health disorders among New Zealand prisoners: New Zealand Department of Corrections Wellington; 2016.

26. Brooke NJ. Needs of Aboriginal and Torres Strait Islander clients residing in Australian residential aged-care facilities. Australian Journal of Rural Health. 2011;19(4):166-70.

27. Atkinson J. Trauma-informed services and trauma-specific care for Indigenous Australian children. Canberra, Australia: AIHW; 2013.

28. Cheng MH. Aboriginal workers key to indigenous health in Australia. The Lancet. 2007;370(9598):1533-6.

29. The Royal Australian and New Zealand College of Psychiatrists. Position Statement 84: Acknowledging and learning from past mental health practices. Melbourne, Australia: RANZCP; 2016.

30. Wirihana R, Smith C. Historical trauma, healing and well-being in Māori communities. MAI Journal. 2014;3(3):2.

31. Nui TPotW. Trauma-Informed Care: Literature Scan. Auckland, New Zealand: Te Pou o te Whakaaro Nui; 2018.

32. National Standards for Mental Health Services: Australian Government; 2010 [Available from: https://www.health.gov.au/sites/default/files/documents/2021/04/national-standards-for-mental-health-services-2010-and-implementation-guidelines-national-standards-for-mental-health-services-2010.pdf]

33. Brown C, D’Almada-Remedios, R., Gilbert, J. O’Leary, J. and Young, N. Gari Yala (Speak the Truth): Centreing the experiences of Aboriginal and/or Torres Strait Islander Australians at work: Diversity Council Australia/Jumbunna Institute; 2020 [Available from: https://www.dca.org.au/research/project/gari-yala-speak-truth-centreing-experiences-aboriginal-andor-torres-strait-islander]

34. Coopes A. Some practical advice and calls to action on embedding cultural safety in health services: Croakey Health Media; 2019 [Available from: https://www.croakey.org/some-practical-advice-and-calls-to-action-on-embedding-cultural-safety-in-health-services/]

35. Cultural supervision: Yamurrah; 2021 [Available from: https://yamurrah.com.au/supervision/.

36. Addressing health inequity – the latest Australian research: Australian Healthcare and Hospitals Association; 2021 [Available from: https://ahha.asn.au/news/addressing-health-inequity-%E2%80%93-latest-australian-research]

37. Boulton A F GHH, Potaka-Osborne M. Realising Whānau Ora Through Community Action: The Role of Māori Community Health Workers. Education for Health. 2009;22(188).

38. Aboriginal Cultural Capability Toolkit: Victorian Public Sector Commission; 2020 [Available from:https://vpsc.vic.gov.au/html-resources/aboriginal-cultural-capability-toolkit/]

39. Cultural Safety and Nursing Education in Aotearoa and Te Waipounamu: Irihapeti Merenia Ramsden; 2002 [Available from: https://www.croakey.org/wp-content/uploads/2017/08/RAMSDEN-I-Cultural-Safety_Full.pdf.]

40. Elana Curtis RJ, David Tipene-Leach, Curtis Walker, Belinda Loring, Sarah-Jane Paine & Papaarangi Reid Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. International Journal for Equity in Health volume. 2019;18(174).

41. Curtis E, Jones R, Tipene-Leach D, Walker C, Loring B, Paine S-J, et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. International Journal for Equity in Health. 2019;18(1):174.

42. Tyson SY. Can cultural competence be achieved without attending to racism? Issues in Mental Health Nursing. 2007;28(12):1341-4.

43. Commissioner. NHaD. Health and Disability Commissioner (Code of Health and Disability Services Consumers' Rights) Regulations; 1996.

44. Truong M, Paradies Y, Priest N. Interventions to improve cultural competency in healthcare: a systematic review of reviews. BMC Health Services Research. 2014;14(1):99.

45. MCNZ. Statement on Cultural Safety; 2019.

46. Williams R. Cultural safety – what does it mean for our work practice? . Australian and New Zealand Journal of Public Health. 1999;23(2), 213-214.

47. AHMAC. National Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2016-2026; 2015.

48. Lacey C, Huria T, Beckert L, Gilles M, Pitama S. The Hui Process: a framework to enhance the doctor-patient relationship with Māori. N Z Med J. 2011;124(1347):72-8.

49. Askew DA, Jennings WJ, Hayman NE, Schluter PJ, Spurling GK. Knowing our patients: a cross-sectional study of adult patients attending an urban Aboriginal and Torres Strait Islander primary healthcare service. Australian Journal of Primary Health. 2019;25(5):449-56.

50. Statement on cultural safety: Medical Council of New Zealand; 2019 [Available from: https://www.mcnz.org.nz/assets/standards/b71d139dca/Statement-on-cultural-safety.pdf]

51. Australia IAH. Cultural Responsiveness Framework 2015 [Available from: https://iaha.com.au/workforce-support/training-and-development/cultural-responsiveness-in-action-training/]

52. Curtis E. Indigenous Positioning in Health Research: The importance of Kaupapa Māori theory-informed practice. AlterNative: An International Journal of Indigenous Peoples. 2016;12(4):396-410.

53. icks KA. Cultural Competence: Facilitating Indigenous Voices Within Health Promotion Competencies. SAGE Open. 2018;8(2):2158244018783218.

54. Indigenous Peoples and Governance: Agreements, treaties and negotiated settlements; 2020 [Available from: https://www.atns.net.au/indigenous-governance]

55. Indigenous Governance Toolkit: The Australian Indigenous Governance Institute; 2013 [Available from: https://toolkit.aigi.com.au/toolkit/1-0-understanding-governance]

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.