HAVING THE HARD CONVERSATIONS

Working with, and through, resistance to cultural safety

PROF. DENNIS MCDERMOTT

POCHE CENTRE FOR INDIGENOUS HEALTH AND WELL-BEING, ADELAIDE, SA, AUSTRALIA

ABORIGINAL HEALTH / CULTURAL SAFETY TRAINING Both students and professionals can struggle to see relevance to practice. Even before Indigenous health / cultural safety introduced … Yr 1 Med Student representatives at my university reported: •  Students finding it hard to see the link between public

health / social determinants of health and science/clinical areas of curriculum … and future practice.

•  Students have requested a reduction in the amount of time dedicated to this segment of the curriculum each week and the introduction of physiology tutorial or a longer anatomy session

BROADER ISSUE OF RESISTANCE

•  In the U.S., class has been identified as a factor in medical student resistance to the role of the social determinants of health in shaping patient presentations*

•  In the Aboriginal context, when we ask students or practising professionals to give regard to the effects of colonisation, the challenge deepens

* (Wear & Aultman, 2005)

ABORIGINAL HEALTH CHALLENGES STUDENTS

•  Aboriginal health statistics disquieting •  Personal narratives can either move

(positively) or disturb •  Challenge to one’s own taken-for-

granted cultural framework •  May rock student certainties, especially

belief in a ‘tolerant’ Australia/Canada

6

GOOD CULTURAL SAFETY TRAINING UNSETTLES

•  Cultural safety foundation of effective practice

•  Building such a foundation may require disassembling existing planks of belief: a transformative unlearning*

•  Involves a journey: begins with discomfort * Ryder, Yarnold and Prideaux, Medical Teacher, 2011

SPECTRUM OF RESPONSE

Emotional responses to Indigenous health and well-being content

1.  ‘Accepting/Keen for More’ Positive, supportive, open to information

2.  ‘Moved/Uncertain’ Moved, sorrowful, ashamed (nationally), wanting to atone, but no feeling of guilt

SPECTRUM OF RESPONSE

3. ‘Disturbed/Flummoxed’ Uncertain, distressed, resentful, feeling personally blamed, betrayed

4.  ‘Hostile/Rejecting’ Angry, rejecting of teaching and teacher, disruptive of class

EMOTIONAL RESPONSES TO INDIGENOUS HEALTH

1. ‘Accepting/Keen for More’ •  I really enjoyed the space for ongoing

reflection provided by both of you’ (CASA09)

•  [The most valuable aspect for me was] learning about Aboriginal history that I didn’t know (CSW09)

•  [The] statistics were eye-opening (CSW09)

EMOTIONAL RESPONSES TO INDIGENOUS HEALTH

2. ‘Moved/Uncertain’ •  I didn’t learn about Aboriginal culture in

school – it’s shameful (CSW09) •  I found the … statistics shocking … These

are real infants, real people – someone’s son or daughter … (NURS2724)

•  ‘Aboriginal issues and well-being are on my radar [now], which sadly wasn’t always so’ (CASA09)

EMOTIONAL RESPONSES TO INDIGENOUS HEALTH

3. ‘Disturbed/Flummoxed’ •  This made me feel guilty, though it was not

my fault (CSW09) •  There were undercurrents of blame in the …

case studies … not helpful to me, who has not implemented past injustices (CSW09)

•  …[U]pset at being made to feel guilty for things I had no control over (CSW09)

EMOTIONAL RESPONSES TO INDIGENOUS HEALTH

4. ‘Hostile/Rejecting’ •  [Why don’t we just] give ‘em a gun and let

them finish themselves off (NURS2724) •  Anger at being confronted (unexpectedly)

with racist cartoons / strong emotional responses of Aboriginal participants (WYN, 08)

•  I feel attacked when I am reading Binan Goonj (NURS2724)

THREAT TO ENGAGEMENT •  Australian experience suggests that the

disquiet produced can be strong enough to lead to disengagement. The development of a culturally-safe practitioner is jeopardised

•  Institutions may similarly feel so challenged as to respond with ‘gate-keeping’, marginalisation and withdrawal of support for both curriculum and staff involved

SERVICES, ORGANISATIONS AND SYSTEMS: KEY SITES

FOR CHANGE? Insights emerging from recent Pan-Indigenous symposium/roundtable: Health Services, Racism & Indigenous Health: Gaining Traction for Systemic Change Flinders University, Adelaide, SA, Australia • 21st and 22nd November 2013 • Day One: Open Symposium

• Day Two: Invited Roundtable

HOW BEST TO GAIN TRACTION?

Prof. Alex Brown (WARU, SAHMRI) •  How do we change the narrative about the

discourse we have? •  How we have these (hard) conversations in

health services? •  How do we get people to buy in?

HOW BEST TO GAIN TRACTION?

The intersection of racism, Indigenous health and health services •  Health service accountability: are reports of

higher levels of psychological distress -when racism is experienced within health services – a spur to action?

•  How to take action is a challenge, but it is critical to persist and learn as we go

FOCUSSING DOWN …

1.  Cultural capital - cultural values as strategies for managing and circumventing racism

2.  Promoting rights and expectations for Indigenous peoples and health services - what is an acceptable or good standard of practice to measure experiences against? What to do when this is not met?

ORGANISATIONAL CHANGE: WORKING WITH RESISTANCE

•  Mainstream services and departments reluctant to take on issues of overt and systemic racism

•  Dismissal or disbelief of non-Indigenous health professionals at the reality of racism and its impact

•  Health professionals who see themselves as non-racist can resist the role of ‘white privilege’

ORGANISATIONAL CHANGE: WORKING WITH RESISTANCE

Prof. LC Chan, Hong Kong University Medical Humanities –

Turning Towards Dissonance

ORGANISATIONAL CHANGE: … THROUGH RESISTANCE

Values and relationship key: •  Core to change is relationship •  Start by talking about values and learning about

each other so a relationship is built, then move to cultural safety training

Top-down process: •  Gaining ownership and commitment by senior

management vital •  Must win the hearts and minds of the leadership

ORGANISATIONAL CHANGE: … THROUGH RESISTANCE

•  Importance of multiple strategies, and engagement of multiple domains, to achieve organisational change – training is critical, but only one strategy

•  Need to develop and maintain an evaluation strategy to track enablers and facilitators of longer-term change

ORGANISATIONAL CHANGE: … THROUGH RESISTANCE

•  Must have dedicated content on racism, cultural safety and culturally respectful services in entry-level health professional training and CPD

•  Accept and expect the spectrum of responses to cultural safety and respect training and organisational change strategies – establish and implement strategies for engaging people who struggle and build in accountability processes

KEY ISSUES FOR RESEARCH AND EVALUATION

•  Can research codify (capture / structure / clarify) the narratives people bring and correlate them with the failures of the system?

•  A strengths-based analysis is needed – what mechanisms of resilience do Indigenous peoples use to manage and survive racism?

•  Recognising and documenting culturally safe practices by non-Indigenous people

KEY ISSUES FOR RESEARCH AND EVALUATION

•  Collaboration with health services – evaluate the impact of intervention to address service racism and develop cultural safety over the long term

•  Evaluation should be done on the impact and outcomes of cultural training to give a more representative picture of progress – both positive and negative impacts

•  How to engage and build in lifelong learning for health professionals, and how to track that journey over time until a shift is achieved

HAVING THOSE HARD CONVERSATIONS

Some Questions: •  How do we turn disengagement into

continuing engagement with Aboriginal health / cultural safety training?

•  What would diminish resistance / make the conversation easier in your field?

•  What would it take to turn your service or organisation into a culturally-safe one?