The Aboriginal and Torres Strait Islander Cultural and Health Training Framework November 2024
The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 3 Contents Artworks 04 Royal Australian College of General Practitioners - Statement of Commitment 12 Acknowledgements 14 Background and Aims 16 Serpent Dreaming 20 Guiding Principles 22 Alignment with other RACGP Education Frameworks and Standards 28 Elements of the Framework 30 Cultural and Health Education Training 32 - Cultural and Health Education Serpent 35 - Guiding Principles 36 - Objectives 37 - Outcomes 38 Cultural Safety 56 - Cultural Safety Serpent 59 - Guiding principles 60 - Objectives 61 - Outcomes 62 Aboriginal and Torres Strait Islander Health Workforce Development 74 - Workforce Development Serpent 77 - Guiding Principles 78 - Objectives 79 - Outcomes 80 Aboriginal and Torres Strait Islander GP Training Pipeline 88 - Training Pipeline Serpent 91 - Guiding Principles 92 - Objectives 93 - Outcomes 94 Recommendations for Implementation 108 Glossary 112 References 115
Holding space for and prioritising Aboriginal and Torres Strait Islander values and wisdom is essential for the transformative change needed to enhance training and health outcomes for our Peoples. DR OLIVIA O’DONOGHUE, YANKUNYTJATJARA AND NARUNGGA NATIONAL CLINICAL HEAD OF ABORIGINAL AND TORRES STRAIT ISLANDER TRAINING 4 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework
The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 5 The artwork for the branding of this Framework includes the RACGP’s ‘Gilimbaa’ artwork. Smooth iridescent skin caresses the earth, unfolding its many layers. Mounds rise up towards the sky; valleys are created. This is the land you belong to; these are the songs you sing. Thick smoke rises through the fresh morning air. Bodies are adorned for this rite of passage in a place of healing. The Rainbow Serpent, the Creation Spirit, moves throughout the land, creating the landscape. It gives People the knowledge and wisdom of the land, ceremony, song, dance and lore - food to eat and medicine to heal. Surrounding the Rainbow Serpent are patterns depicting locations across Australia from the Torres Straits through Queensland across to the Northern Territory, Western Australia, South Australia, New South Wales, Victoria, the ACT and Tasmania. The patterns also refer to carvings, markings, tracks, scarification, and body adornments – what is found in the landscape and People’s interpretation of this landscape is reflected on their own bodies. This artwork also represents the traditional possum skin cloaks worn by the People of the Victorian region. The squares of the checkerboard design represent individual possum skins that are sewn together to form the cloak. Old and new meld as this ancient design is placed on the modern - the College’s graduation gown. Through this, The Royal Australian College of General Practitioners pays its respects to Aboriginal and Torres Strait Islander groups across Australia and to the land on which it teaches, learns, and practices the art of medicine. GILIMBAA ARTWORK ‘Creation Story - Healing Place’
Proud descendant of the Meriam People from the Komet Clan in the Torres Strait, Kayla is a medical doctor who graduated from the University of Queensland in 2017, working in Brisbane before moving to Denmark in 2020. “When I was younger, I was always inspired by and loved creating art, but never had the chance to focus solely on it. I found while studying medicine that creating ‘artistic’ study notes of basic human anatomy, physiology and pathophysiology was one of the best ways for me to learn.” “While waiting for my medical registration to be approved here, I’ve started to create anatomy-inspired images based off our stories, our internal structures and our barriers in healthcare.” Growing up in an Torres Strait Islander family, with many family members having chronic medical conditions, the disconnect between Indigenous Australians and the healthcare sector has always been evident for Arabena-Byrnes. “In Australia, Aboriginal and Torres Strait People were rarely made to feel welcome or represented in healthcare settings. And historically medical institutions have caused generational harm to my People. But I hope by reclaiming Indigenous knowledge, stories and representation through medical-based art that we can find a way to bridge the divide between patient and provider and learning about ourselves and our bodies in the process.” Kayla Arabena-Byrnes ARTIST PROFILE 6 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework
The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 7 In this artwork, Kayla seeks to express the symbolism of the Ouroboros Serpent, a motif resonating deeply within many Aboriginal and Torres Strait Islander Peoples. The ouroboros works as a metaphor for the journey toward cultural safety and symbolises awareness, sensitivity, competency, and safety in cross-cultural interactions. The Serpent illustrates the ongoing commitment to acknowledging and respecting cultural differences and engaging in the self-reflection of dynamics within our healthcare areas. The vibrant colours and dynamic patterns within the Serpent’s body are inspired by the landscapes and traditions of Aboriginal and Torres Strait Islander Peoples. Kayla uses rich and diverse earth tones within the snake to represent Aboriginal culture, while the precise and contrasting linework is used to symbolise Torres Strait Islander culture. Just as the Serpent renews the land and creates new life, the framework for cultural safety aims to nurture and sustain the well-being of our communities. By embracing the teachings of the Rainbow Serpent and the wisdom of Aboriginal and Torres Strait Islander cultures, we can foster healthcare environments where all can thrive and feel genuinely safe. Ouroboros ‘Cultural Safety’ In ‘Education and Training’, Kayla explores the influence of the Rainbow Serpent, the creator being in many Aboriginal cultures, representing knowledge and cultural learning. The artwork features the Serpent as a pyramid, representing crucial layers in the learning process: connection, reinforcing, scaffolding, immersion, and relational. These layers focus on the importance of being connected to one’s beliefs, continuous reflection, building upon experiences, cultural immersion, and the holistic concept of interconnectedness. The vibrant colours and intricate patterns within the Serpent reflect the landscapes and traditions of Aboriginal and Torres Strait Islander cultures. Using rich and diverse earth tones within the snake to represent Aboriginal culture, the precise and contrasting linework is used to symbolise Torres Strait Islander culture. “The Serpent’s transformative ability reflects the power of education, renewal, and nurturing what is sacred to our communities.” ‘Education and Training’ emphasises the need to surround guiding principles in cultural safety within our healthcare environments, by fostering spaces where all can thrive and feel safe. Pyramid ‘Education and Training’
Artist Kathryn Dalmer is of the Gawthorne Ward line of the Three Rivers Tribe, Wiradjuri Nation - the largest original nation in what is known as NSW. Despite spending much time on country and holding a deep connection to culture, Kathryn hasn’t lived on country for any length of time. “My family was dispersed across NSW and south-east Queensland as a result of actions associated with the white Australia policy. Somehow we have retained and regained our connection to country, culture and each other.” A contemporary Indigenous artist, a mother of three amazing daughters, a wife, a daughter, a sister, a cousin, an aunty. “I am also an active community member, mentor, counsellor, social worker, and medical doctor. “My journey as an exhibiting artist began whilst living on Eora country and sitting with the amazing Yuin and Gadigal women of La Parouse. “Connecting with each other and our culture through our art is something that we foster and hold dearly in our family.” Kathryn’s art is an expression of “all the things that I am and all the things that I channel – my culture, our history, our land, our spirit. “I use a combination of traditional Aboriginal symbols and styles with contemporary imagery and colours using acrylic on canvas, on stretched canvas images of my original photography or 3D objects such a vases.” Kathryn Dalmer ‘kdal’ ARTIST PROFILE 8 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework
The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 9 The landscape rainbow colours within this Serpent are separated in a progressive lineal design to represent stages of the GP workforce and individual career development in becoming a Fellowed general practitioner. The GP ‘Workforce Development’ journey begins with our first concepts of profession and career in high school (red). The next two stages represented, Allied Health professionals (ochre) and undergraduate tertiary education (golden), are not always a lineal progression, and are included here as important progressive steps of GP career development and pools for GP recruitment. These are both areas where increased exposure to general practice as a career occur. Undertaking a medical degree (green), junior doctor training (blue-green) and being a GP registrar are lineal progressive steps. All the knowledge and experience from these components come together in the art of undertaking general practice (rainbow colours of the neck) and culminate in our practice of being Fellowed general practitioners within RACGP (corporate teal of the Serpent head). Traditional x-ray art has also been used in this piece to demonstrate the deep history of healing and medicine within our first nations cultures. This has always involved a connection to the animals, lands and spirits. Look closely to identify the Serpent’s heart, lungs and GI tract. Workforce Development is multi-layered. The heart and soul of each individual is what it is made of. Strong connections to each other, our history and our culture are essential components for our Aboriginal and Torres Strait Islander workforce. ‘Workforce Development’ In this piece, the rainbow colours within the Serpent are represented along its length. All colours run alongside each other as elements of our lives and life journeys run along congruently and become increasingly defined as separate elements of us as we grow and develop as individuals. This represents the influences of the GP training pipeline as it is comprised of and impacted by various aspects of life including personal growth, our community roles and family responsibilities, and our professional growth and career development. Progression towards being Fellowed general practitioners is represented by the teal colour of the head of the Serpent, the corporate colour of our College, RACGP. The symbols surrounding and woven amongst this coiled Serpent are representations of the various influences on that pipeline. Traditional symbols of family and kinship groups are both at the centre of the piece, and at the bottom right. The top left symbol shows communities and connections between communities while other symbols dispersed within the coil show meeting places, families, smaller gatherings and people connecting. Communities, education, group learning, mentorship and a sense of belonging are essential to being a GP. The influence starts with our first exposure to healthcare as babies with our parents and care givers. Various touch points and influences along and surrounding the curves of the coiled Serpent contribute to opportunities for career progression in either clinical general practice, supervision, medical education and research. This Serpent and the surrounding symbols are a visual representation of the nature of general practice, and the unextractable influences individual practitioner, patients, families, communities and the RACGP as a college have on each other. These influences are emphasised when we consider our Indigenous workforce Training Pipeline. ‘Training Pipeline’
The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 11 These Serpents representing the ‘Education and Training’ and ‘Cultural Safety’ are reproduced here in the shape of half an infinity symbol. They await their counterparts GP ‘Training Pipeline’ and ‘Workforce Development’ to complete the infinity symbol. Kayla Arabena-Byrnes These Serpents representing the GP ‘Training Pipeline’ and ‘Workforce Development’ are reproduced here in the shape of half an infinity symbol. They await their counterparts ‘Education and Training’ and ‘Cultural Safety’ to complete the infinity symbol. Kathryn Dalmer ‘kdal’ Infinity Symbol
12 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework Royal Australian College of General Practitioners Statement of Commitment In 2024, the Royal Australian College of General Practitioners (RACGP) would like to reinforce our commitment to recognising the rights and sovereignty of Aboriginal and Torres Strait Islander Peoples through real action. We understand that this commitment takes more than just words, however heartfelt they may be, and requires comprehensive and system-wide action to ensure these rights are visible and active within the fabric and structure of our organisation. We have listened to the Aboriginal and Torres Strait Islander leaders within our College, and we are working with them to embed Aboriginal and Torres Strait Islander governance within our training program. The RACGP has long understood that recognition of rights and sovereignty are an essential part of the process to close the gap on health inequalities. We’ve been a public supporter of the Uluru Statement from the Heart since 2018. The resilience and strength that Aboriginal and Torres Strait Islander Peoples have exhibited in the face of the ongoing challenges and exclusion brought about by colonisation must be acknowledged. “This commitment takes more than just words, however heartfelt they may be, and requires comprehensive and system-wide action”
The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 13 The comprehensive knowledge, systems and cultural practices that supported this resistance and provided healing as a central part of Aboriginal and Torres Strait Islander cultures for over 60,000 years, must now provide a basis for how we can all learn and move forward. The Aboriginal and Torres Strait Islander medical and cultural leaders within the RACGP have proudly led and developed the Aboriginal and Torres Strait Islander Cultural and Health Training Framework. This Framework, while grounded in Aboriginal and Torres Strait Islander led research, also incorporates and honours the lived experience of those whose lives reflect the issues outlined in that research every single day. The RACGP recognises it has a role to play in truth telling, about how the medical profession has been part of the colonising structures that have depicted Aboriginal and Torres Strait Islander Peoples as responsible for health disparities, without taking into account the structural barriers and unequal access to power and resources that Aboriginal and Torres Strait Islander Peoples have faced. This Framework is part of the process to change these narratives that continue to impact not only the wider Aboriginal and Torres Strait Islander communities, but the people who work within the RACGP and their families. The Framework is as much about change within our organisation and contributing to the individual journey towards healing as it is about the broader health system level outcomes. We want to acknowledge our partnership within the Joint Colleges Training Services Pty Ltd (JCTS), a joint venture with the Australian College of Rural and Remote Medicine (ACRRM). Both Joint Colleges Training Services and ACRRM have played important roles in contributing to the development of the Framework and will be key in its implementation. The RACGP Board and Executive welcome the Aboriginal and Torres Strait Islander Cultural and Health Training Framework as an integral part of our education governance and encourage all our members and staff to embrace this important step forward in reconciliation and learning. Dr Nicole Higgins President, RACGP Dr Lara Roeske Board Chair, RACGP Ms Georgina van de Water CEO, RACGP
Acknowledgments The RACGP Aboriginal and Torres Strait Islander Cultural and Health Training Framework (the Framework) was developed through an Aboriginal and Torres Strait Islander led process. This was a highly consultative project, drawing on the cultural and health expertise and leadership of many Aboriginal and Torres Strait Islander Peoples, both within the RACGP and amongst key stakeholder groups. We acknowledge and pay respects to the diversity and strength of the cultures represented throughout this process. In addition, we thank the many non-Indigenous people who generously provided their time and expertise. PROJECT TEAM (Initial project team included Dr Danielle Arabena and Dr Kali Hayward.) Dr Olivia O’Donoghue Yankunytjatjara and Narungga Project Oversight National Clinical Head of Aboriginal and Torres Strait Islander Training Paula Myott Non-Indigenous living on Durramurrgal Country Project Manager Dr Simone Raye Bardi and Jabbir Jabbir Senior Medical Educator President of the Australian Indigenous Doctors’ Association (AIDA) Devinia Binell Barngarla-Kokatha Wirangu Senior Cultural Educator 14 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework
The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 15 STEERING COMMITTEE A/Prof James Brown Non-Indigenous living on Gunaikurnai Country Project Sponsor, RACGP National Director of Training Dr Danielle Arabena Meriam Mer RACGP Co-National Clinical Lead in Aboriginal and Torres Strait Islander Health Dr Kali Hayward Warnman RACGP Co-National Clinical Lead in Aboriginal and Torres Strait Islander Health Ada Parry Marrithiyel Cultural and Education Advisor RACGP National Faculty of Aboriginal and Torres Strait Islander Health Dr Karen Nicholls Malu Kuiwi Chair of RACGP National Faculty of Aboriginal and Torres Strait Islander Health Georgina van de Water Non-Indigenous living on the land of the Darug nation RACGP Chief Executive Officer Anthony Paulson Worimi Joint Colleges Training Services Interim General Manager Dr Judith Culliver Non-Indigenous living on Wurundjeri Country RACGP National Clinical Lead for Education Development and Strategy, Frameworks and Accreditation. Prof Marlene Drysdale Wiradjuri Chair of the National Cultural Educators and Cultural Mentors Network Kyra Moss Non-Indigenous living on Turrbal and Jagera Country ACRRM, General Manager Education Services Donna Burns Wiradjuri Australian Indigenous Doctors Association OTHER CONTRIBUTORS Josephine Borthwick, non-Indigenous living on Bundjalung Country and the RACGP Evaluation Lead, provided valuable input and advice on the evaluation strategy for the Framework. Many stakeholders were engaged through numerous advisory and focus groups, including Aboriginal and Torres Strait Islander medical students, junior medical officers, GP registrars, GP Fellows, cultural educators and mentors, supervisors and practice managers. We thank them for sharing their invaluable lived experience and insights into engaging with GP training. The project drew on the expertise of many non-Indigenous RACGP staff, whose in-depth knowledge of the training program provided important input into the Framework. Project completed by Aboriginal and Torres Strait Islander medical education leadership team Olivia O’Donoghue, Danielle Arabena and Kali Hayward. The RACGP Board and Executive have provided generous and enthusiastic support for the development and establishment of the Framework. This project is funded predominantly through a grant from the Commonwealth Department of Health as part of the RACGP – Vocational General Practice Training Grant. Pictured: Aboriginal and Torres Strait Islander medical education team members
16 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework I HAVE COME TO LEARN THROUGH THE GENEROSITY OF OTHERS SHARING THEIR RICH EXPERIENCE, THAT MEANINGFUL ENGAGEMENT WITH ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLES IS ESSENTIAL WHEREVER THE FRAMEWORK IS APPLIED. GEORGINA VAN DE WATER RACGP CHIEF EXECUTIVE OFFICER
The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 17 Background The Royal Australian College of General Practitioners (RACGP) is committed to developing and supporting a culturally safe and reflective general practitioner (GP) workforce that works effectively with Aboriginal and Torres Strait Islander patients and communities. The RACGP Reconciliation Action Plan (RAP) vision for reconciliation is an organisation and GP profession free from racism, where all GPs can, and do provide culturally safe healthcare, grounded in mutual respect and trust. A key strategy for addressing Aboriginal and Torres Strait Islander health inequity is training that is evidenced to result in changing practice and in health outcomes (Reath, 2019). During the development of the RACGP Training Program, which includes Aboriginal and Torres Strait Islander Cultural and Health Training, it was identified that a comprehensive framework was needed at a national level to cohesively underpin all the work required in relation to Aboriginal and Torres Strait Islander Cultural and Health Training as well as training and workforce pipeline development. As a key partner in the Joint Colleges Training Services Pty Ltd (JCTS), a joint venture of the Australian College of Rural and Remote Medicine (ACRRM) and the RACGP, ACRRM has played a valuable role in the Steering Committee and development of the Aboriginal and Torres Strait Islander Cultural and Health Training Framework (the Framework). The Framework outlines an approach to how the principles underpinning it can shape the shared GP training activities for our respective Fellowship training programs. Through the Joint Colleges Training Services funding, the development and implementation of the Aboriginal and Torres Strait Islander health strategic plans will reflect this approach. All general practice and rural generalist registrars, of both colleges, through key collaborations on areas such as training sites, placements and cultural education, will have the opportunity to engage with the Framework as it provides an ongoing process to reflect on, and embed Aboriginal and Torres Strait Islander values and ways of knowing, being and doing throughout the training programs. The RACGP values ACRRM’s ongoing role in the implementation and evaluation of the Framework. Background and Aims
18 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework The Aboriginal and Torres Strait Islander Cultural and Health Training Framework brings an approach to educational structure and delivery that incorporates deconstructing colonial-driven educational concepts and recognises Aboriginal and Torres Strait Islander Peoples’ leadership, values and priorities in health and health training. The Framework puts Aboriginal and Torres Strait Islander sovereignty and self-determination at the forefront of approaches to general practice training. This broadens the Aboriginal and Torres Strait Islander health discourse by paying attention to historical and political determinants of health and well-being, as well as the social and cultural determinants. Aboriginal and Torres Strait Islander ways of knowing, being and doing are embedded in every part of the Framework and its application from design, implementation and importantly governance. This is part of the structural reorientation needed for transformative change for the RACGP’s training programs. The Framework is principles-based and provides a nationally consistent approach to the RACGP Aboriginal and Torres Strait Islander Cultural and Health Training programs. It provides focus and direction, and a way of working together, while remaining flexible enough to be contextualised at a local level. By not being prescriptive, it allows local cultural and language differences, histories, and relationships to be considered, reflecting the strong connection to Country unique to every Aboriginal and Torres Strait Islander community. Acknowledging and honouring the strength in the diversity of Aboriginal and Torres Strait Islander cultures is an important part of the Framework. Aims
The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 19 As a principles-based Framework, it is a ‘lens’ through which all parts of the Training Program are considered. Through the principles, a structure is provided that can be used to interrogate our underlying assumptions and existing approaches. The Framework, through the process of decolonisation, requires emphasising critical thinking and reflexivity skills to challenge existing western/scientific/bio medical assumptions and constructs about Aboriginal and Torres Strait Islander Peoples, culture, and knowledge plus the underlying pedagogy of teaching and learning. The RACGP recognises the rights of Aboriginal and Torres Strait Islander Peoples to sovereignty and selfdetermination, and by embedding Aboriginal and Torres Strait Islander governance, aims to use this Framework to ensure the Indigenisation of the training program. This is an RACGP-wide change process. Which works towards acknowledging and incorporating Aboriginal and Torres Strait Islander knowledge systems, cultures, values, interests, aspirations, and epistemologies (Rigney, 2017). The key distinction with a process of Indigenisation is that it is focused on ‘learning from’ Aboriginal and Torres Strait Islander Peoples, rather than only ‘learning about’ Aboriginal and Torres Strait Islander Peoples (Guerzoni, 2020). Aboriginal and Torres Strait Islander People engaged in this work have all endured the impact of colonisation. This impact is reflected in the dismal health statistics often quoted, literature and media - and in the ongoing negative interactions that Aboriginal and Torres Strait Islander People continue to experience. The impact of this sits very close to the surface at all times. There is an urgent need to shift the burden of addressing the impact of colonisation from just those most affected, to making it a responsibility for all. This Framework is a core pillar of the RACGP education governance structure. It sits alongside the Educational Framework, Progressive Capability Profile of the General Practitioner, Curriculum, Syllabus, policies and training standards. The Framework is a guiding instrument for all who are involved in the training journey including: registrars, supervisors, medical educators, cultural educators, and cultural mentors, as well as the RACGP staff supporting this work. The Framework itself is dynamic and will continue to evolve throughout its implementation, application, and evaluation, ensuring it enhances training and remains cognisant of Aboriginal and Torres Strait islander values and needs.
Serpent Dreaming has been chosen to help illustrate this Framework as it demonstrates the beginning of all things, the creation, transformation, reflections, rebirth, renewal, and nurturing of what is important and sacred, essentially what is ‘core’. 20 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework
The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 21 Serpent Dreaming The Serpent (or Rainbow Serpent) is a significant and powerful creator being across many Aboriginal and Torres Strait Islander cultures and countries. The Serpent is a creator of geography (hills, gorges, creeks, rivers, and lakes), People, plants and animals and is intricately linked to waterways. The Serpent may even control the local elements, creating wind, rain and storms when needed for the land and Peoples to thrive or to protect them from malicious forces. Serpent Dreaming is shared through song lines, stories, art, and dance and offers valuable moral and ethical lessons across Australia. The Serpent has many different names and appearances across the numerous Aboriginal and Torres Strait Islander groups of Australia, and the sites where the Serpent rests are highly respected and sacred sites. In Western Australia ‘Wagyl’ (Waugal/Waagal) created the waterways of the Noongar People surrounding Perth. In central Australia ‘Wanampi’ is a fierce protector of the waterholes for the Anangu People of the Pitjantjatjara/Yankunytjatjara language groups, and ‘Goorialla’ is the great creator of the land, waterways, People, plants and animals of the Lardil People of Northern Queensland. On the lands and waterways where Serpent Dreaming is strong, Aboriginal and Torres Strait Islander Peoples pay respect to the great creator by acknowledging its presence and letting it know when they are approaching the spaces it inhabits, what their intentions are for their visit, and to ask permission to proceed. Some of these sacred sites are forbidden for people to enter due to their cultural and spiritual significance. Singing to waterways, sharing sweat or rubbing soil on the body are some of the practices used to notify the Serpent of one’s approach. In many traditional stories the Rainbow Serpent is heralded for its ability to shed its skin, renew the land, and create new lifeforms. Sometimes by swallowing humans who may have behaved unethically (or for its own mischievous purposes), then using its blood to transform them into other creatures and plants to sustain and enhance the environment. The Serpent and Serpent Dreaming has been chosen to help illustrate this Framework as it demonstrates the beginning of all things, the creation, transformation, reflections, rebirth, renewal, and nurturing of what is important and sacred, essentially what is ‘core’. The Serpent can change its shape, colours, and dimensions to mould the land, create and recreate spaces for living things to thrive. The Aboriginal and Torres Strait Islander Cultural and Health Training Framework is designed to ensure the RACGP has embedded the guiding principles within training and education for Aboriginal and Torres Strait Islander Peoples to thrive. This Framework heralds new approaches and will evolve and mature with space and time.
22 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework The Aboriginal and Torres Strait Islander Cultural and Health Training Framework is underpinned by twelve guiding principles. These principles have been identified by the Aboriginal and Torres Strait Islander members of the Framework Steering Committee and are supported by Aboriginal and Torres Strait Islander led research. These principles provide focus and direction, and a way of working together. The principles are mutually reinforcing and help to provide a way to navigate complex and dynamic areas of work. The principles are not prescriptive in how they are applied, as they can respond to circumstances, overlap, and evolve. This enables them to be situationally interpreted and locally contextualised. TRAUMA INFORMED RACISM, DISCRIMINATION AND PRIVILEGE VALUE AND WAYS OF KNOWING, BEING AND DOING STRENGTHS BASED INDIGENOUS DATA SOVERIGNTY EQUITY DECOLONISATION LEADERSHIP SOVEREIGNTY CULTURAL SAFETY SELF-DETERMINATION INDIGENISATION Guiding Principles
Sovereignty Sovereignty is exercising autonomy, both at an individual level and as a ‘People’ (Larissa Behrendt, 2003). It acknowledges Aboriginal and Torres Strait Islander rights, ownership and authority in Australia which was never ceded in terms of land, law and its People. This recognises that Aboriginal and Torres Strait Islander governance and participation is inherent to the effectiveness and success of programs. By foregrounding the principle of sovereignty, RACGP are choosing to pay particular attention to the historical and political factors that have shaped the lives and health of Aboriginal and Torres Strait Islander Peoples. This principle is necessary for the RACGP Aboriginal and Torres Strait Islander Cultural and Health Training Framework to embody the kind of systemic and structural change required to improve health outcomes, also aligning with the Uluru Statement from the Heart. Self-determination Self-determination is the collective right of Aboriginal and Torres Strait Islander Peoples to determine their own political, economic, social and cultural development and develop their own systems of governance, it is an essential approach to overcoming disadvantage (National Aboriginal Health Strategy Working Party, 1989). Self-determination is achieved by expanding and holding space within the existing RACGP governance structures for Aboriginal and Torres Strait Islander Peoples. Evidence shows that self-determination in decision making to create Aboriginal and Torres Strait Islander led solutions for health can mitigate the impacts of colonialism for Aboriginal and Torres Strait Islander Peoples, improving health and wellbeing. Decolonisation According to a Māori academic, decolonisation involves critically understanding the culturally biased assumptions, motivations, and values underlying knowledge construction (Prof Linda Tuhiwai Smith, 2012). The western cultural bias in medical education replicates colonial power structures and consequently leads to systems and processes that are less effective for Aboriginal and Torres Strait Islander Peoples and learners. By unpacking these biases and centring Aboriginal and Torres Strait Islander Peoples in the analysis, RACGP can develop the critical thinking and reflexivity to challenge these structures and enhance systems and processes that will be beneficial to all. The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 23
24 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework Cultural Safety Cultural safety goes beyond respecting all People; it requires lifelong learning and reflective practice to prevent underlying assumptions, stereotypes, and conscious and unconscious biases from negatively impacting Aboriginal and Torres Strait Islander Peoples. It applies to patients and all Aboriginal and Torres Strait Islander individuals within the RACGP and is judged by them as the recipients of the care, attitudes and behaviours. It includes ongoing training and policies addressing racism and discrimination, emphasising the practitioner’s responsibility for culturally safe practice through ongoing critical reflection and awareness of their own cultural and professional influences. (Papps and Ramsden 1996, Ramsden 2002, Williams 1999, Brascoupé and Waters 2009, cited in Watego, Singh, Macoun, 2021). ‘Cultural safety is determined by Aboriginal and Torres Strait Islander individuals, families, and communities. Culturally safe practise 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.’ - Australian Health Practitioner Regulation Agency (Ahpra) Aboriginal and Torres Strait Islander Leadership Aboriginal and Torres Strait Islander leadership and career development focuses on place, People, relationships, and processes that address power imbalances to achieve equitable outcomes. (Duke et al 2021). To effectively embed Aboriginal and Torres Strait Islander governance and selfdetermination within RACGP structures, it is essential to invest in and support the leadership development of Aboriginal and Torres Strait Islander Peoples, through the application of Aboriginal and Torres Strait Islander knowledge systems and with succession planning necessary to ensure continuity and reduce burnout. Indigenisation Indigenisation involves institutional change for Indigenous inclusion, underpinned by the principles of recognising rights and respecting Indigenous Peoples’ knowledge and cultures, while privileging Indigenous values, interests, aspirations, and epistemologies. This process integrates Indigenous knowledge and perspectives, discipline-specific content, reflexive practice, evaluative assessment, and pedagogy. Using methods like yarning and storytelling to promote holistic, person-forming education that includes spiritual, relational, social, and environmental connections (Rigney, 2017).
Strengths-based Approaches A strengths-based approach centres the People and relationships of Aboriginal and Torres Strait Islander communities, highlighting their history, positionality, and dynamic cultures as sources of resilience and success, rather than focusing on projects, policies or comparisons to the dominant culture. This contrasts with a deficit approach, which frames Aboriginal and Torres Strait Islander identity and health negatively, as a burden, where being Aboriginal and Torres Strait Islander becomes the problem focus, a source of failure and inferiority. This overlooks historical, political, and structural issues and reinforces commonly held attitudes, beliefs and stereotypes. It is emerging that persistent deficit discourse also has a negative impact on the health of First Nations Peoples similarly to racism, discrimination and colonising methodologies. The RACGP will prioritise a strengths-based approach which asserts the humanity, strength, and resilience of Aboriginal and Torres Strait Islander Peoples. This includes actively identifying deficit and negative narratives or approaches that reinforce problematic stereotypes. A strengths-based practice requires a reconfiguring of relationships of power, of attending to structure over stereotypes, and privileging Aboriginal and Torres Strait Islander ways of knowing, being and doing. (Askew et al, 2020). Racism, Discrimination and Privilege Ongoing colonising processes and marginalisation perpetuate all levels of racism including intrapersonal, interpersonal, and institutional racism profoundly impacting the health and wellbeing of Aboriginal and Torres Strait Islander Peoples. Medical education has historically been complicit in these inequitable structures, requiring a critical examination of its culture to address embedded racism, discrimination and privilege. By embedding this guiding principle, the RACGP reinforces its zero tolerance on racism stance and will strive to eliminate racism in education and training at all levels, including identified system review. Equity The World Health Organisation defines health equity as: “…the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically, geographically, or otherwise. Some dimensions of identity that individuals or groups are categorised by include race, ethnicity, gender, sexuality, employment and socioeconomic status, disability, immigration status, geography, and more.” This Framework and the Aboriginal and Torres Strait Islander governance underpinning it aim to achieve equitable outcomes for Aboriginal and Torres Strait Islander Peoples across health, education, and research within the RACGP, benefiting patients, registrars, and GP Fellows. Recognising that the health system is profoundly shaped by a hierarchical western biomedical model, it is essential to address cultural bias in medical education to achieve these equitable outcomes (Naidu and Abimola, 2022). The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 25
26 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework Aboriginal and Torres Strait Islander Values, and Ways of Knowing, Being and Doing Many cultural capability frameworks use the three domains of knowing, being and doing to underpin them and engender the process of continuous and progressive learning. These concepts are derived from Aboriginal and Torres Strait Islander values systems where everything is inter-connected and evolving at the same time, requiring deep learning and re-evaluation. Aboriginal and Torres Strait Islander cultures are diverse, but share common epistemological threads such as sovereignty, collectivism, sustainability and relationality, which will be used as foundations for this Framework and its initiatives. In the Framework, RACGP foregrounds values like dadirri (deep listening), seeing ‘twoways’ (considering both sides simultaneously), Meriam Peoples’ Malo’s Law (keeping to your own path), kanyini (interconnectedness through stewardship), ngapartji ngapartji (reciprocity), and ganma (new knowledge from intersecting Indigenous and western knowledge), emphasising a holistic worldview and connection to Country and kinship. Indigenous Data Sovereignty Indigenous data sovereignty and governance enable Aboriginal and Torres Strait Islander Peoples to control their representation and accurately reflect their stories, countering statistical representations that lack context and history (Walter, 2016). Exercising this sovereignty allows for effective decision-making to support their communities. In view of this the RACGP Framework should include a data governance policy that focuses on the needs and supports accurate data generation for Aboriginal and Torres Strait Islander Peoples. Trauma-informed Approaches For Aboriginal and Torres Strait Islander People, trauma-informed care involves understanding the widespread impact of trauma and recognises potential paths for recovery. It identifies signs and symptoms of trauma in patients, families, and staff, and integrates this knowledge into policies, procedures, and practices to enhance patient engagement and outcomes. It also requires taking active steps to avoid re-traumatisation during care delivery. Trauma-Informed approaches acknowledge and respond to the pervasive nature of trauma. The cumulative effect of historical and intergenerational trauma that severely reduces the capacity of Aboriginal and Torres Strait Islander Peoples to fully and positively participate in their lives and communities, leading to widespread disadvantage (healingfoundation.org.au). Embedding trauma-informed approaches in teaching and learning will support Aboriginal and Torres Strait Islander trainees and staff. Providing trauma-informed care education to trainees and GPs will enhance capacity for culturally responsive care and improve health outcomes for Aboriginal and Torres Strait Islander Peoples.
THE GUIDING PRINCIPLES GIVE US ALL A COHESIVE FOUNDATION FOR OUR WORK TOWARDS IMPROVING THE HEALTH OF ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLES. The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 27
Alignment with the RACGP Educational Framework The Aboriginal and Torres Strait Islander Cultural and Health Training Framework is an integral and essential part of the RACGP educational framework. It encompasses the training model, evaluation model, and the three key RACGP education pillars of: the RACGP curriculum and syllabus; the progressive capability profile of the general practitioner; and policies and standards. The Aboriginal and Torres Strait Islander Cultural and Health Framework provides a key foundation for the other educational structures and systems. This Framework supports the expansion and enhancement of Aboriginal and Torres Strait Islander Cultural and Health Training within the RACGP training and education programs. 28 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework
The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 29 CULTURAL AND HEALTH, EDUCATION AND TRAINING CULTURAL SAFETY ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH WORKFORCE DEVELOPMENT ABORIGINAL AND TORRES STRAIT ISLANDER GP TRAINING PIPELINE Pictured: Indigenous General Practice Trainee Network (IGPTN) cultural activity
30 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework Elements of the Framework Pictured: Smoking Ceremony by Kuma Kaaru on Kaurna Country
Cultural safety Cultural safety is an essential element of the Framework and is interwoven throughout its entirety. The Framework takes a holistic approach to embedding continuous and ongoing cultural safety principles and learning. Aboriginal and Torres Strait Islander health workforce development To meet the health needs in Aboriginal and Torres Strait Islander communities, it is imperative to increase the numbers of GPs, both nonIndigenous and Aboriginal and Torres Strait Islander doctors, who choose to work in this sector. This element provides guidance on how to encourage and support passion and enthusiasm for Aboriginal and Torres Strait Islander health as well as the quality and quantity of practitioners for Aboriginal and Torres Strait Islander communities. Cultural and health, education and training This element contextualises the embedding of Aboriginal and Torres Strait Islander values and ways of learning and teaching within the curriculum, syllabus and training programs, including education, assessment, evaluation, policies and procedures that support training. It allows for the exploration of different systems of inquiry and opportunities for enhancement of RACGP education and training programs. Aboriginal and Torres Strait Islander GP training pipeline Increasing the numbers of Aboriginal and Torres Strait Islander doctors who are entering the GP training pipeline is a social justice issue of training and workforce equity. Reaching population parity (or an increase in numbers) will both enhance the health system and health outcomes for all Peoples. A culturally safe and responsive pathway for Aboriginal and Torres Strait Islander doctors into GP training and beyond Fellowship is imperative to these aims. The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 31
32 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework Input from Aboriginal and Torres Strait Islander communities and Peoples is vital to the success of GP training. SIMONE RAYE BARDI AND JABBIR JABBIR SENIOR MEDICAL EDUCATOR PROJECT TEAM
The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 33 Cultural and Health Education Training Cultural and Health, Education and Training Serpent 35 Guiding Principles 36 Objectives 37 Outcomes 38
Aboriginal and Torres Strait Islander approaches to education and learning The Framework will assist the RACGP to incorporate and embed Aboriginal and Torres Strait Islander teaching methodologies and strategies into its entire education and training program especially, but not exclusive to, areas of the delivery of Aboriginal and Torres Strait Islander cultural and health education. Aboriginal and Torres Strait Islander epistemologies will undoubtably also afford enhancements to other areas of the educational and training program. The Framework will also address culturally appropriate assessment of GP registrars across the spectrum of knowing, doing and showing. Aboriginal and Torres Strait Islander People have a long history of essential knowledge transfer from generation to generation through song lines, music, dance, art and oral narratives. To Aboriginal and Torres Strait Islander Peoples, learning is an immersive and experiential endeavour. Educational practices from infancy recognise the autonomy of the child and learning through exploration, trial and error, knowing roles and responsibilities and through relationships (Secretariat of National Aboriginal and Islander Child Care, 2011). Learning is spiral and complexities are built-up over time; it is layered, relational and contextual. Ethical and moral principles are taught through creation stories and other cultural narratives. (Munro et al, 2019). Holistic, physical, mental and spiritual wellbeing has been practiced for centuries by Aboriginal and Torres Strait Islander Peoples and is strongly related to the health and wellbeing of the land and waterways in which People are connected. Physical and spiritual healing practices of traditional healers, such as Ngangkari, have been passed from one generation to the next through kinship lines, stories, learning in practice and mentoring. This Framework respects and values the knowledge and knowledge transfer of Aboriginal and Torres Strait Islander traditional healers. Prof Stanley Wilson, Cree Elder from Canada and co-founder of the First Nations Graduate Education at the University of Alberta coined the concept of Indigegogy (Wilson and Schellhammer, 2021). This term is a combination of ‘Indigenous’ and ‘pedagogy’. It describes how he developed his own ways of teaching using First Nations ways of thinking and doing things, transferring this into education and learning to provide himself and others with a stronger sense of authority over their own methods, rather than those imposed by a western style teaching system. Professor Wilson also describes the relational way in which First Nations People undertake education, including exploration, discussion, immersion and connection as important elements of learning and teaching. The Framework gives guidance on the educational and training structure that embeds Aboriginal and Torres Strait Islander concepts and other appropriate First Nations methodologies. 34 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework
Cultural and Health, Education and Training Serpent The Education and Training Serpent conceptualises five layers of learning using Aboriginal and Torres Strait Islander knowledge and teaching methodologies. FIVE LAYERS OF LEARNING Connection Being safe and connected to one’s own beliefs, attitudes, behaviours and actions, and the impact they have on interactions with Aboriginal and Torres Strait Islander People. Reinforcing Continuous reflection on implementation and practice to enhance cultural competencies and skills. Scaffolding Building on learning experiences in concentric ways to consolidate and gain new cultural competencies. Immersion Cultural immersion provides opportunities for social learning and being present with educators, peers, Aboriginal and Torres Strait Islander People and Country in the moment of learning. Relational The foundational concept of building relationships, respect and trust, where knowledge can be generated and shared. The Aboriginal and Torres Strait Islander Cultural and Health Training Framework 35
36 The Aboriginal and Torres Strait Islander Cultural and Health Training Framework Guiding Principles Sovereignty, leadership, equity, selfdetermination and governance in education and training will be demonstrated through the strategic and meaningful engagement of Aboriginal and Torres Strait Islander medical educators and cultural educators in the educational programs. They will lead the development, implementation and embedding of Aboriginal and Torres Strait Islander educational values and principles. Decolonisation requires dissecting and unpacking some of the western frameworks that drive our current educational and training systems and processes, especially those that are ineffective at producing appropriate and sustainable outcomes for teaching and learning in Aboriginal and Torres Strait Islander contexts. Indigenisation is reflected though valuing, incorporating and adequately resourcing Aboriginal and Torres Strait Islander education methodologies into training including experiential and immersive learning. Educational design will be culturally safe and cultural safety teaching will be embedded throughout the training program. Racism and discrimination will be proactively addressed and removed from educational systems and content and the effects of privilege minimised. Education and training will use a strengths-based approach, eliminating negative discourse and deficit approaches by engaging Aboriginal and Torres Strait Islander ways of knowing, being, doing and leveraging cultural strengths and capabilities. This includes actively deconstructing negative stereotyping within the educational content. Trauma-informed teaching and assessment approaches are incorporated across the whole scope of training. Aboriginal and Torres Strait Islander health educational and training data will be carefully managed, culturally appropriate and exercise principles of Indigenous data sovereignty.
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