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Cultural safety for Aboriginal and Torres Strait Islander children and young people

Cultural safety for Aboriginal and Torres Strait Islander children and young people: A background paper to inform work on child safe organisations

1 Introduction

This background paper discusses cultural safety for Aboriginal and Torres Strait Islander children and young people to inform work on child-safe organisations in Australia. The Australian Human Rights Commission is leading the development of National Principles for Child Safe Organisations. This project has been commissioned by the Commonwealth Government, in consultation with states and territories, as part of the Third Action Plan (2015-2018) for the National Framework for Protecting Australia’s Children. It builds on the recent findings and recommendations of the Royal Commission into Institutional Responses to Child Sexual Abuse. Guidance and resources on child-safe cultures in organisational settings, covering both small scale and complex organisational structures, are currently being developed. Developing an understanding of and practical strategies to implement culturally safe environments is a key aspect of this work.

The term ‘cultural safety’ was initially developed by Maori nurses in New Zealand and the discussion about cultural safety is both most rigorous and most extensive within Indigenous contexts. This paper begins by placing cultural safety in its historic context, explaining the origins of the term. A brief consideration of what is meant by ‘cultural competence’ follows, with consideration given to the debate on whether or not cultural safety and cultural competence can be thought of as complementary perspectives. Current uses of the concept of cultural safety in literature about Aboriginal and Torres Strait Islander communities are discussed, with a focus on children and young people in particular.

2 The New Zealand origins of cultural safety

It is generally acknowledged that the term cultural safety originated in New Zealand in the 1980s.[1] The concept was first proposed by Maori midwifery students in response to feeling unsafe within the predominantly Anglo (Pakeha) educational setting they were trained in. It was then further developed to provide an explanation for the poor uptake of health services by Maori in general. The writings of Indigenous scholar Irihapeti Ramsden[2] have been especially pivotal to the formation of this concept.[3]

The implementation of principles of cultural safety (Kawa Whakaruruhau in Maori) was primarily conceptualised as a way of redressing Indigenous health inequities in New Zealand. Cultural safety was intended to reduce alienation from existing health care services by ensuring that organisations in general, as well as individual employees: understood the broad contours of the history of colonial violence and dispossession producing health inequalities; and also undertook to suspend their own ethnocentric views in favour of respecting alternative worldviews and cultural practices, prioritising the needs and preferences of their clients.[4] A recognition of the power differentials inherent in service provider/client interactions remains a core component of the concept. Since 1992, cultural safety has been integrated as a compulsory component of the New Zealand nursing curriculum.

A range of terms including the word ‘culture’ have been used to understand Maori health and to think about ways of tackling inequalities in access to health care and in service provision. These terms include cultural difference, cultural awareness, cultural sensitivity and biculturalism (both Maori and Pakeha contexts).[5] According to Ramsden, all of these terms are inadequate to the task of addressing the political context in which Maori healthcare is situated.[6] Cultural safety was conceived as a way of moving the conversation away from deficit-based discourses and the associated individualising of health concerns toward a recognition that processes of colonisation, including the loss or attenuation of traditional beliefs, practices and language, needed to be taken into account in any explanation of, and attempt to improve, health outcomes for Indigenous peoples.[7]

Cultural safety provides a framework for understanding how health policies and practices create situations of risk for Indigenous peoples, in part because these policies and practices do not respond adequately to intergenerational trauma. This approach has primarily been taken up in countries, including Canada, to address the inequalities experienced by ‘First Nations’ peoples.[8] The concept of cultural safety has also been widely used in Australia, with Aboriginal and Torres Strait Islander scholars adapting the concept to fit their particular sociocultural and historical circumstances.

Summary

· The concept of cultural safety originated in New Zealand in the 1980s as a way to redress Maori health inequities.

· Acknowledging the negative and ongoing impacts of colonisation on Indigenous peoples is a central component of cultural safety.

3 Cultural safety and cultural competence

The word ‘culture’ is used in diverse ways in policy, service delivery and organisational contexts. Ramsden proposed a progression towards culturally safe practice in three steps:

  1. cultural awareness, defined as understanding that differences exist
  2. cultural sensitivity, defined as accepting the legitimacy of difference and reflecting on the impact of the service provider’s life experience and positioning on others
  3. cultural safety, as defined by recipients of care or services.[9]

This three-step model incorporates a number of different ‘culture’ terms within an overarching framework and suggests a degree of compatibility. However, other conceptualisations have emphasised the philosophical incompatibility of cultural safety with some of these other terms.[10] In particular, cultural safety is often contrasted (both negatively and positively) with cultural competence.

New Zealand proponents of the cultural safety movement have distanced themselves from cultural competence, a concept originally developed in the United States in the field of Transcultural Nursing.[11] Cultural competence has been defined as ‘the ability of systems to provide care to patients with diverse values, beliefs and behaviours, including tailoring delivery to meet patients’ social, cultural and linguistic needs’.[12] Critics of cultural competence have argued that the concept is more suited to a multicultural context than an Indigenous one.[13] Others have gone further, seeing cultural competence as a potentially reductive paradigm, focused on superficial understandings of cultural traditions rather than on an understanding of the factors that produce and maintain inequalities.[14]

In practice, however, cultural safety and cultural competence are often blended together as complementary approaches. Cultural competence has been expanded to include elements originally associated with cultural safety, such as considering how one’s own cultural positioning impacts on service provision and acknowledging the negative impacts of colonial history, including dispossession and institutionalisation. Ruth DeSouza, a New Zealand nursing clinician and educator, has made a case that both ‘paradigms have value in providing practical and theoretical mechanisms for enhancing and advancing the wellbeing of communities’.[16] We now frequently see work in the field of cultural competence that incorporates aspects of the social justice perspective that originally defined cultural safety.

Summary

· Cultural safety is usually seen as encompassing both cultural awareness and cultural sensitivity.

· Cultural safety is often contrasted with cultural competence, with some researchers arguing that cultural safety is a more robust term with a stronger focus on the causes of inequality.

· In practice, cultural safety and cultural competence are often treated as complementary approaches.

4 Cultural safety for Aboriginal and Torres Strait Islander peoples

The value of a cultural safety framework has been increasingly recognised in Australia, especially by organisations that either represent and/or provide services to Aboriginal and Torres Strait Islander peoples. In his Native Title Report 2011, former Aboriginal and Torres Strait Islander Social Justice Commissioner, Mick Gooda, recommended: ‘That Aboriginal and Torres Strait Islander communities and their organisations work together to develop engagement and governance frameworks that promote cultural safety’ thereby ensuring consistency with the United Nations Declaration on the Rights of Indigenous Peoples (the Declaration).[17] The Declaration recognises the need to respect, promote and strengthen Indigenous cultures and traditions, including ‘the right not to be subjected to forced assimilation or destruction of their culture’[18] and ‘the right to practice and revitalize their cultural traditions and customs’.[19]

As is the case in New Zealand, in Australia cultural safety has been most extensively used in the health sector. Literature on the effects of intergenerational trauma on Aboriginal and Torres Strait Islander children and families has contributed to our understanding of the ongoing negative impacts of previous policies and practices as well as the importance of trauma and healing informed practices. As the Bringing Them Home Report noted, ‘the actions of the past resonate in the present and will continue to do so in the future’.[20]

The Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM), a national peak body founded in 1997, endorses cultural safety as an approach that aims to address these issues. Cultural safety is viewed by CATSINaM ‘as the final step on a continuum of nursing and/or midwifery care that includes cultural awareness, cultural sensitivity, cultural knowledge, cultural respect and cultural competence’.[21]

The Australian Indigenous Doctors’ Association (AIDA) also endorse cultural safety. AIDA’s 2013 position paper on cultural safety adopts a hierarchical model of cultural frameworks, positioning cultural safety at the top of a continuum with cultural awareness at the bottom. Their advocacy embraces the twin aims of promoting culturally safe learning environments for Aboriginal and Torres Strait Islander medical students and doctors; and culturally safe service delivery to patients.[22]

The National Aboriginal and Torres Strait Islander Health Workers Association (NATSHIWA) have developed a cultural safety framework, comprising eight interrelated domains.[23]

The Victorian Aboriginal Community Controlled Health Organisation (VACCHO) offer cultural safety training, which aims to enhance the health sector’s capacity to improve program policy design and delivery of culturally safe health services to Aboriginal and Torres Strait Islander peoples. VACCHO offers the following definition of cultural safety:

Cultural Safety is being acceptable to difference, having the ability to analyse power imbalances, institutional discrimination, colonisation and relationships with settlers. Cultural safety is about providing quality health care that fits with the familiar cultural values and norms of the person accessing the service, that may differ from your own and/or the dominant culture.[25]

The Aboriginal Health Council of Western Australia also offers cultural safety training to improve the quality of service delivered by health care providers and the experience of those services for Aboriginal and Torres Strait Islander peoples.[26]

Indigenous Allied Health Australia (IAHA) developed a framework, launched in 2015 using the term ‘cultural responsiveness’, to meet the need for practical strategies to build cultural safety using strengths-based and action-oriented approaches. The six key capabilities identified in the IAHA Framework detail ways of enhancing cultural responsiveness. These capabilities are: respect for centrality of culture; self-awareness; proactivity; inclusive engagement; leadership; and responsibility and accountability.[27]

The Royal Australian College of General Practitioners (RACGP) draws a distinction between ‘cultural awareness education’ and ‘cultural safety training’, considering the former as the first building block towards cultural safety with the latter having a clear focus on outcomes for health services and their patients. In other words, cultural safety training aims to produce behavioural changes which, in turn, lead to practice improvements. RACGP offers an online introduction to Aboriginal and Torres Strait Islander cultural awareness and recommends participation in accredited cultural safety training.[28]

The fundamental link between culture and wellbeing has been explicitly recognised in the Australian Government’s National Aboriginal and Torres Strait Islander Health Plan 2013-2023.[29] The delivery of clinically appropriate care that is culturally safe, responsive and accessible for all Aboriginal and Torres Strait Islander people is identified as a key goal within this Plan.[30]

Martin Laverty, Dennis McDermott and Tom Calma have recently argued that there is an urgent need for collaboration ‘on a systematic revision of standards to embed culturally safe practice and develop health settings free of racism’.[31] Peak Indigenous health bodies have consistently put the case that increasing the likelihood of culturally safe clinical care may contribute to substantial health improvements for Aboriginal and Torres Strait Islander peoples. In 2017, the Australian Commission on Safety and Quality in Health Care (ACSQHC) defined six actions that specifically meet the needs of Aboriginal and Torres Strait Islander people within the National Safety and Quality Health Service Standards. In meeting the Clinical Governance Standard, health service organisations should: demonstrate a welcoming environment that recognises the importance of cultural beliefs and practices; improve the cultural awareness and cultural competency of their workforce; and ensure that appropriate safety and quality priorities are established, implemented and monitored.[32]

The link between culture and wellbeing is affirmed by research demonstrating that interventions that include opportunities for expression of cultural identities can have beneficial effects for Aboriginal and Torres Strait Islander peoples, and are associated with measurable improvements in health. Activities such as actively learning Indigenous languages, connecting to Country and expressing cultural identity through art and performance were all found to have measurably beneficial effects in the first ever Australian systematic review of quantitative outcomes of cultural interventions designed to improve Indigenous health and wellbeing.[33]

Alfred Dockery, using data from the Australian Bureau of Statistic’s 2002 National Aboriginal and Torres Strait Islander Social Survey (NATSISS), found that strong attachment to traditional culture seems to be statistically associated with better outcomes across a diverse range of dimensions of socio-economic wellbeing, including educational attainment.[34] Recovering and reclaiming traditional cultural practices in the context of a history of dispossession and assimilation remains an ongoing challenge. Scholarship on the link between cultural safety and health provides support to the more general argument that culture is not the problem; rather, it is essential to wellbeing.

Summary

· Cultural safety is increasingly used in organisations representing and/or providing services to Aboriginal and Torres Strait Islander peoples, especially in the health sector.

· Aboriginal and Torres Strait Islander scholars have adapted cultural safety concepts developed in New Zealand to fit Australian circumstances, emphasising the negative legacy of colonisation and dispossession, as well as the positive impact of learning about and fostering identification with Indigenous culture.

· Research indicates a robust link between culture and wellbeing.

5 Cultural safety for Aboriginal and Torres Strait Islander children and young people

The concept of cultural safety is now increasingly accepted in many areas of policy and service provision that impact on Aboriginal and Torres Strait Islander children and young people. Australia has obligations under both the Declaration[35] and the United Nations Convention on the Rights of the Child (the Convention)[36] to protect children’s connections to culture and community as a means of fostering a strong sense of personal identity and belonging. These include Article 29(c), referring to respect for cultural identity as integral to education and Article 30, which states that Indigenous children shall not be denied the right to enjoy their own culture. The specific references to Indigenous children in the Convention are indicative of the recognition that they require special measures in order to fully enjoy their cultural rights. In particular, States parties are urged to eliminate discriminatory attitudes and practices, including racism, and to ensure that Indigenous children have access to culturally appropriate services in the areas of health, education, recreation and sports, social services and juvenile justice.[37]

In the Australian context, Daryl Higgins has argued that, in order to be effective, child safety must be treated as a societal issue, adopting holistic family support that recognises the fundamental importance of cultural safety.[38] A broadly similar view has been advocated in the Family Matters campaign, which is calling for a national strategy to improve the safety and wellbeing of Aboriginal and Torres Strait Islander children, and eliminating their over-representation in out-of-home care (OOHC).[39] SNAICC offer the following definition of cultural safety for Aboriginal and Torres Strait Islander children:

…cultural safety encompasses the child being provided with a safe, nurturing and positive environment where they are comfortable with being themselves, expressing their culture…their spiritual and belief systems, and they are supported by the carer and family.

…cultural safety is when you as the carer provide the child with a safe home, which respects their Aboriginality and therefore encourages their sense of self and identity.[40]

Muriel Bamblett, CEO of the Victorian Aboriginal Child Care Agency, has evoked the metaphor of culture as a possum skin cloak, providing warmth and connection to ancestors, creator spirits and the land, as part of her view that programmes must seek to strengthen the safety, wellbeing and cultural connectedness of Aboriginal and Torres Strait Islander children, individuals and families. In discussing the work of the Victorian Aboriginal Child Care Agency, Bamblett posits culture as a vital protective factor, promoting resilience.[41]

The First 1000 Days Australia movement calls for increased action and investment in improving the first two years of children’s lives. It provides a further example of the pivotal link between culture and wellbeing for Aboriginal and Torres Strait Islander children.[42] Kerry Arabena, Stacey Panozzo and Rebecca Ritte, writing about their experience of the Australian First 1000 Days movement, point to the need to incorporate strong community governance processes, respectfully engaging community and incorporating local priorities and strengths.[43] They also highlight the importance of recognising the heterogeneity evident throughout urban, regional/rural and remote settings, a diversity that is sometimes masked by the use of ‘culture’ in the singular.[44] The reference to ‘cultures’ here serves as a reminder that research now indicates that Aboriginal and Torres Strait Islander children have different needs and variable access to services, depending on whether they live in urban, regional or remote locations.[45]

In 2017, the ongoing dislocation of Aboriginal and Torres Strait Islander children from family and culture was highlighted in the Report of the Royal Commission and Board of Inquiry into the Protection and Detention of Children in the Northern Territory (NT). The NT Royal Commission found that youth detention services failed to support the rights of Aboriginal children and young people to build and maintain their connection to culture and language, recommending an approach to youth detention ‘that recognises and uses the value of connection to culture’.[46]

The final report of the Royal Commission into Institutional Responses to Child Sexual Abuse (the Royal Commission), released in December 2017, made a number of recommendations about the importance of cultural safety for Aboriginal and Torres Strait Islander children. These include:

  • the funding of Aboriginal and Torres Strait Islander healing approaches for victims and survivors of child sexual abuse (Recommendation 9.2)
  • the development and implementation of plans to fully implement the Aboriginal and Torres Strait Islander Child Placement Principle (Recommendation 12.20)
  • the need for state and territory governments to consider further strategies for the cultural safety of Aboriginal and Torres Strait Islander children in youth detention including recruiting and developing Aboriginal and Torres Strait Islander staff, providing access to interpreters, facilitating detainees’ connections with family, community and culture, having policies and procedures in place that respect the cultural practices of different clan groups and building professional capacity in cultural competence for staff (Recommendation 15.5).[47]

The Criminal Justice report, released by the Royal Commission in August 2017, highlighted the need to take account of any relevant cultural safety issues in police responses to reports of child sexual abuse (Recommendations 3.b.ii and 12.a).[48]

More broadly, the Royal Commission concluded that cultural safety is an important element of Standard 4: ‘Equity is upheld and diverse needs are taken into account’, which is one of ten Child Safe Standards.[49] The Royal Commission proposed that these safety standards be made mandatory and be adopted by all organisations working with and for children. The Royal Commission specifically noted that Aboriginal and Torres Strait Islander children may be less likely to disclose abuse for fear of authorities intruding into their family and community, based on historic experiences of systemic racism. Access to trusted Aboriginal adults who understand the child’s cultural context, a strong connection to culture and positive relationships with family were identified as salient factors in these children’s safety.[50]

Summary

· Cultural safety is increasingly accepted in many areas of policy and service provision that impact on Aboriginal and Torres Strait Islander children and youth.

· The NT Royal Commission (2017) found that youth detention services failed to support the rights of Aboriginal children and young people to build and maintain their connection to culture and language.

· The Royal Commission into Institutional Responses to Child Sexual Abuse (2017) made a number of recommendations about cultural safety for Aboriginal and Torres Strait Islander children and underscored the importance of cultural safety in implementing Standard 4: ‘Equity is upheld and diverse needs are taken into account’.

6 Conclusion

Australian Indigenous scholars, advocates and activists have adopted the concept of cultural safety, fitting it to their particular socio-historical circumstances, activities, concerns and goals. The importance of cultural safety for Aboriginal and Torres Strait Islander children and young people is attested to by this scholarship, by policy work in a range of contexts and by recent Royal Commission recommendations and Child Safe Standards, some of which directly address the need for and benefits of cultural safety.

The challenge now is to identify how concepts of cultural safety can be best understood in the contexts of all organisations, Indigenous and non-Indigenous, providing services to Aboriginal and Torres Strait Islander children, as well as the practical assistance and guidance required to embed and sustain policy and practice change.

[1] Elaine Papps and Irihapeti Ramsden, ‘Cultural Safety in Nursing: The New Zealand Experience’ (1996) 8(5) International Journal for Quality in Health Care 491.

[2] See, for example Irihapeti Ramsden, ‘Cultural Safety in Nursing Education in Aotearoa (New Zealand)’ (1993) 8(3) Nursing Praxis in New Zealand 4; Irihapeti Ramsden, ‘Cultural safety/Kawa Whakaruruhau Ten Years On: A Personal Overview’ 2000 15(1) Nursing Praxis in New Zealand 4.

[3] Kerry Taylor and Pauline Guerin, Health Care and Indigenous Australians: Cultural Safety in Practice (Palgrave Macmillan, 2010) 14.

[4] Daryl Higgins, Community Development Approaches to Safety and Wellbeing of Indigenous Children (June 2010) Resource Sheet 1, Australian Institute of Family Studies. At https://aifs.gov.au/publications/community-development-approaches-safety-and-wellbeing-indigenous-children (viewed 28 November 2017); Irihapeti Ramsden, ‘Towards Cultural Safety’ in Dianne Wepa (ed), Cultural Safety in Aotearoa New Zealand (Pearson Education New Zealand 2005) 2; Sandy Richardson, ‘Aoteaoroa/New Zealand Nursing: From Eugenics To Cultural Safety’ (2004) 11(1) Nursing Inquiry 35.

[5] Sandy Richardson, ‘Aoteaoroa/New Zealand Nursing: From Eugenics to Cultural Safety’ (2004) 11(1) Nursing Inquiry 35, 36.

[6] Irihapeti Ramsden, ‘Towards Cultural Safety’ in Dianne Wepa (ed), Cultural Safety in Aotearoa New Zealand (Pearson Education New Zealand, 2005) 2, 6.

[7] Ruth DeSouza, ‘Wellness for All: The Possibilities of Cultural Safety and Cultural Competence in New Zealand’ (2008) 13(2) Journal of Research in Nursing 125, 130; Sandy Richardson, ‘Aoteaoroa/New Zealand Nursing: From Eugenics to Cultural Safety’ (2004) 11(1) Nursing Inquiry 35, 37.

[8] Annette Browne, Colleen Varcoe, Victoria Smye, Sheryl Reimer-Kirkham, Judith Lynam and Sabrina Wong, ‘Cultural safety and the Challenges of Translating Critically Oriented Knowledge in Practice’ (2009) 10(3) Nursing Philosophy 167.

[9] Irihapeti Ramsden, Cultural Safety and Nursing Education in Aotearoa and Te Waipounamu (PhD Thesis, Victoria University Wellington, 2002) 117.

[10] Ruth DeSouza, ‘Wellness for All: The Possibilities of Cultural Safety and Cultural Competence in New Zealand’ (2008) 13(2) Journal of Research in Nursing 125, 133.

[11] See Madeleine Leininger, ‘What is Transcultural Nursing and Culturally Competent Care?’ (1999) 10(1) Journal of Transcultural Nursing 9.

[12] Joseph Betancourt, Alexander Green and J. Emilio Carrillo, Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. Field Report (The Commonwealth Fund, 2002) v.; cited in Ruth DeSouza, ‘Wellness for All: The Possibilities of Cultural Safety and Cultural Competence in New Zealand’ (2008) 13(2) Journal of Research in Nursing 125, 131.

[13] Ruth DeSouza, ‘Wellness for All: The Possibilities of Cultural Safety and Cultural Competence in New Zealand’ (2008) 13(2) Journal of Research in Nursing 125, 125.

[14] For example Anne Coup, ‘Cultural safety and Culturally Congruent Care: A Comparative Analysis of Irihapeti Ramsden’s and Madeleine Leininger’s Educational Projects for Practice’ (1996) 11(1) Nursing Praxis in New Zealand 4; Sandy Richardson, ‘Aoteaoroa/New Zealand Nursing: From Eugenics to Cultural Safety’ (2004) 11(1) Nursing Inquiry 35, 38.

[15] Adapted from Irihapeti Ramsden, Cultural Safety and Nursing Education in Aotearoa and Te Waipounamu (PhD Thesis, Victoria University Wellington, 2002) 117.

[16] Ruth DeSouza, ‘Wellness for All: The Possibilities of Cultural Safety and Cultural Competence in New Zealand’ (2008) 13(2) Journal of Research in Nursing 125, 133-4.

[17] Mick Gooda, Native Title Report 2011, Australian Human Rights Commission, Recommendation 7.

[18] United Nations Declaration on the Rights of Indigenous Peoples, GA Resolution 61/295, UN Doc A/61/L.67 (2007) art 8(1).

[19] United Nations Declaration on the Rights of Indigenous Peoples, GA Resolution 61/295, UN Doc A/61/L.67 (2007) art 11(1).

[20] Human Rights and Equal Opportunity Commission, Bringing Them Home: Report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families (1997) 4.

[21] Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, Cultural Safety Position Statement (2014). At catsinam.org.au/static/.../files/cultural-safety-endorsed-march-2014-wfginzphsxbz.pdf (viewed 21 November 2017).

[22] Australian Indigenous Doctors’ Association, Cultural Safety for Aboriginal and Torres Strait Islander Doctors, Medical Students and Patients, Position Paper (2013). At https://www.aida.org.au/wp-content/uploads/2015/03/Cultural_Safety.pdf (viewed 21 November 2017).

[23] National Aboriginal and Torres Strait Islander Health Worker Association, Cultural Safety Framework. At http://www.natsihwa.org.au/sites/default/files/publications/NATSIHWA-Cultural%20Safety-Framework%20Summary.pdf (viewed 12 December 2017).

[24] National Aboriginal and Torres Strait Islander Health Worker Association, Cultural Safety Framework. At http://www.natsihwa.org.au/sites/default/files/publications/NATSIHWA-Cultural%20Safety-Framework%20Summary.pdf (viewed 12 December 2017), 7.

[25] Victorian Aboriginal Community Controlled Health Organisation, An Introduction to Cultural Safety in Aboriginal Health. At http://www.vaccho.org.au/assets/01-RESOURCES/TOPIC-AREA/CULTURAL-SAFETY/CS-4-HOURS.pdf (viewed 21 November 2017).

[26] The Aboriginal Health Council of Western Australia, Cultural Safety Training (2018). At https://www.ahcwa.org.au/cst (viewed 16 January 2018).

[27] Indigenous Allied Health Australia, Cultural Responsiveness in Action: An IAHA Framework (2015). At http://iaha.com.au/policy/cultural-responsiveness/ (viewed 16 January 2018).

[28] Royal Australian College of General Practitioners, Aboriginal and Torres Strait Islander Health, Cultural Awareness Education and Cultural Safety Training (2011). At https://www.racgp.org.au/download/Documents/AHU/NFATSIH-Cultural-awareness-and-safety-training.PDF (viewed 16 January 2018).

[29] Australian Government, National Aboriginal and Torres Strait Islander Health Plan 2013-2023 (2013). At http://www.health.gov.au/natsihp (viewed 12 December 2017).

[30] Australian Government, National Aboriginal and Torres Strait Islander Health Plan 2013-2023 (2013). At http://www.health.gov.au/natsihp (viewed 12 December 2017), 16.

[31] Martin Laverty, Dennis McDermott and Tom Calma, ‘Embedding Cultural Safety in Australia’s Main Health Care Standards’ (2017) 207(1) Medical Journal of Australia 15, 16.

[32] Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. User Guide For Aboriginal and Torres Strait Islander Health (2017), 3. At https://www.safetyandquality.gov.au/wp-content/uploads/2017/12/National-Safety-and-Quality-Health-Service-Standards-User-Guide-for-Aboriginal-and-Torres-Strait-Islander-Health.pdf (viewed 16 January 2018).

[33] Sarah MacLean, Rebecca Ritte, Alister Thorpe, Shaun Ewen and Kerry Arabena, ‘Health and Wellbeing Outcomes of Programs for Indigenous Australians That Include Strategies to Enable the Expression of Cultural Identities: A Systematic Review’ (2017) 23(4) Australian Journal of Primary Health 309.

[34] Alfred Dockery, ‘Culture and Wellbeing: The Case of Indigenous Australians’ (2010) 99(2) Social Indicators Research 315.

[35] United Nations Declaration on the Rights of Indigenous Peoples, GA Resolution 61/295, UN Doc A/61/L.67 (2007).

[36] Convention on the Rights of the Child, opened for signature 20 November 1989, 1577 UNTS 3 (entered into force 2 September 1990).

[37] Committee on the Rights of the Child, United Nations Convention on the Rights of the Child, General Comment No. 11, Indigenous children and their rights under the Convention (2009). At http://tbinternet.ohchr.org/_layouts/treatybodyexternal/Download.aspx?symbolno=CRC%2fC%2fGC%2f11&Lang=en (viewed 23 January 2018).

[38] Daryl Higgins, Community Development Approaches to Safety and Wellbeing of Indigenous Children (June 2010) Resource Sheet 1, Australian Institute of Family Studies. At https://aifs.gov.au/publications/community-development-approaches-safety-and-wellbeing-indigenous-children (viewed 28 November 2017).

[39] SNAICC, Save the Children Australia, University of Melbourne, Centre for Evidence and Implementation, The Family Matters Report: Measuring Trends to Turn the Tide on Aboriginal and Torres Strait Islander Child Safety and Removal (2016). At www.familymatters.org.au/wpcontent/uploads/.../Family_Matters_Report_2016.pdf (viewed 21 November 2017).

[40] SNAICC, What is Cultural Safety? At http://www.supportingcarers.snaicc.org.au/connecting-to-culture/cultural-safety/ (viewed 15 November 2017).

[41] Muriel Bamblett, ‘The Possum Skin Cloak–Being Warmed by Culture’ (2014) 39(3) Children Australia 134.

[42] Kerry Arabena, Stacey Panozzo and Rebecca Ritte, ‘”What Hope Can Look Like”: The First 1000 Days-Aboriginal and Torres Strait Islander Children and their Families’ (2016) 44 Developing Practice: The Child, Youth and Family Work Journal, 25.

[43] Kerry Arabena, Stacey Panozzo and Rebecca Ritte, ‘”What Hope Can Look Like”: The First 1000 Days-Aboriginal and Torres Strait Islander Children and their Families’ (2016) 44 Developing Practice: The Child, Youth and Family Work Journal, 25, 26-27.

[44] Kerry Arabena, Stacey Panozzo and Rebecca Ritte, ‘”What Hope Can Look Like”: The First 1000 Days-Aboriginal and Torres Strait Islander Children and their Families’ (2016) 44 Developing Practice: The Child, Youth and Family Work Journal, 25, 32.

[45] For example, Danielle Clucas, Kylie Carville, Christine Connors, Bart Currie, Jonathan Carapetis and Ross Andrews, ‘Disease burden and health-care clinic attendances for young children in remote Aboriginal communities of northern Australia’ (2008) 86(4) Bulletin of the World Health Organization 275; Hasantha Gunasekera, Peter Morris, John Daniels, Sophie Couzos and Jonathan Craig, ‘Otitis media in Aboriginal children: the discordance between burden of illness and access to services in rural/remote and urban Australia’ (2009) 45(7-8) Journal of Paediatrics and Child Health 425;Dorothy Mackerras, Alison Reid, Susan M. Sayers, Gurmeet Singh, Kathryn Flynn and Ingrid Bucens, ‘Growth and morbidity in children in the Aboriginal Birth Cohort Study: the urban–remote differential’ (2003) 178(2) The Medical Journal of Australia 56.

[46] Commonwealth, Royal Commission and Board of Inquiry Into the Detention of Children in the Northern Territory. National Report (2017) vol 1, 19-20.

[47] Royal Commission into Institutional Responses to Child Sexual Abuse. Final Report Recommendations (2017), 30, 40, 46. At https://www.childabuseroyalcommission.gov.au/sites/default/files/final_report_-_recommendations.pdf (viewed 8 January 2018).

[48] Royal Commission into Institutional Responses to Child Sexual Abuse. Criminal Justice Report (2017) Executive Summary and Parts I-II, 91, 95. At https://www.childabuseroyalcommission.gov.au/sites/default/files/file-list/final_report_-_criminal_justice_report_-_executive_summary_and_parts_i_to_ii.pdf (viewed 8 January 2018).

[49] Royal Commission into Institutional Responses to Child Sexual Abuse. Final Report. Making Institutions Child Safe. Volume 6 (2017), 213. At https://www.childabuseroyalcommission.gov.au/sites/default/files/final_report_-_volume_6_making_institutions_child_safe.pdf (viewed 10 January 2018).

[50] Royal Commission into Institutional Responses to Child Sexual Abuse. Final Report. Making Institutions Child Safe. Volume 6 (2017), 170-172. At https://www.childabuseroyalcommission.gov.au/sites/default/files/final_report_-_volume_6_making_institutions_child_safe.pdf (viewed 10 January 2018).

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