The National Aboriginal and Torres Strait Islander Health Plan 2021–2031 (Department of Health 2021) defines cultural safety as follows:

‘Cultural safety is about how care is provided, rather than what care is provided. It requires practitioners to deliver safe, accessible and responsive health care that is free of racism by:
•    recognising and responding to the power imbalance between practitioner and patient
•    reflecting on their knowledge, skills, attitudes, practising behaviours, and conscious and unconscious biases.’

Importantly, cultural safety is determined by Aboriginal and Torres Strait Islander individuals, families and communities (see below). 

Right now in Australia, however, not all healthcare is culturally safe. 

In 2022, 20 per cent of Aboriginal and Torres Strait Islander adults reported that either they or their families had been racially discriminated against by healthcare workers including doctors, nurses and other medical professionals during the preceding 12 months (Australian Institute of Health and Welfare 2023).

Cultural safety training, sometimes called cultural awareness, cultural responsiveness or cultural capability training, provides healthcare professionals with the tools and capabilities required to deliver safe, accessible and responsive healthcare free of racism.

A national strategy for cultural safety in healthcare

The Australian Health Practitioner Regulation Agency (Ahpra) and the National Registration and Accreditation Scheme have set up an Aboriginal and Torres Strait Islander Health Strategy Group to develop and deliver the Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020–2025 (the Strategy) (Ahpra 2020). 

The Strategy focuses on making patient safety for Aboriginal and Torres Islander peoples the norm and on the inextricably linked elements of clinical and cultural safety.

‘Aboriginal and Torres Strait Islander people have the right to access and work in healthcare free from racism. 

'This is a human right. However, a significant gap in cultural safety knowledge and application is putting Aboriginal and Torres Strait Islander people’s lives at risk,’ says Karl Briscoe, co-chair of the Aboriginal and Torres Strait Islander Health Strategy Group.

‘The Strategy aims to address this gap and eliminate racism in healthcare. 

'Aboriginal and Torres Strait Islander health professionals, practitioners, peak bodies and race scholars have shaped this transformative work.’

The Strategy has been endorsed by 43 organisations, academics and individuals, including accreditation authorities such as the Australian Physiotherapy Council (APC), Ahpra and the National Boards. 

As part of the Strategy, physiotherapy programs at universities around Australia must include cultural safety training for accreditation.

‘While there are no mandated cultural safety requirements for physiotherapy registration, all physiotherapy programs of study in Australia are required to include foundational training in cultural safety as part of their program,’ said a spokesperson for the Physiotherapy Board of Australia.

‘As part of the internationally trained physiotherapy practitioner pathway, all physiotherapists are required to participate in cultural safety training before obtaining their practising certificate and subsequent registration in Australia. 

'In addition, many public health services have cultural safety training requirements and make training accessible for health practitioners to attend.’

To support the Strategy’s aim of eliminating racism from the health system, all physiotherapists have an obligation to provide culturally safe healthcare. 

Legislative reform in 2022 embedded cultural safety and the elimination of racism in healthcare into the National Law. 

The reforms were tested in 2023. In a landmark case, a Canberra-based non-Indigenous doctor was banned from practising for 12 months for ‘discriminatory and offensive’ behaviour towards an Indigenous doctor (Ahpra 2023), sending a clear message that culturally unsafe behaviour is unlawful and carries substantive penalties.

Ahpra and the Physiotherapy Board strongly encourage physiotherapists who have been practising for many years to participate in cultural safety training (see breakout below).

‘It is important to ensure all Australians feel safe when receiving and working in health services. 

'The Physiotherapy Board and Ahpra are also looking at various strategies to increase participation in cultural safety training and awareness in the future,’ said the Physiotherapy Board spokesperson.

Karl highlights further changes in progress through the Strategy’s Cultural Safety Accreditation and Continuing Professional Development (ACPD) Upskilling Framework and Strategy.

‘The Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy also sets out a clear pathway to creating behavioural change. 

'Embedding cultural safety as part of ongoing CPD for all 16 regulated health professions will ensure consistency and accountability to protect Aboriginal and Torres Strait Islander patients and health workers. 

'It’s about 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,’ he says.

Why is cultural safety training important?

Some physiotherapists will ask why they need to do cultural safety training if they don’t typically work with Aboriginal and Torres Strait Islander people.

Associate Professor Michael Reynolds, a Wiradjuri physiotherapist, chair of the APC, former chair of the APA’s Aboriginal and Torres Strait Islander Health Committee and deputy head of the School of Allied Health (NSW) at Australian Catholic University, says the conversation should start with understanding why we need to put a person’s culture at the centre of their care.

Mick Reynolds.

‘When it comes to cultural safety, people don’t always see the importance of looking at Aboriginal and Torres Strait Islander culture specifically. 

'They ask, what about my culture? And what about other cultures?’ Michael says.

He points out that Aboriginal and Torres Strait Islander peoples in Australia are disproportionately affected by a range of practices and policies, both current and historical, that have a big impact on their health outcomes.

‘Aboriginal and Torres Strait Islander people aren’t often afforded the same access as others and there’s a variety of reasons for that,’ Michael says.

But while Aboriginal and Torres Strait Islander people are at the centre of cultural awareness and safety conversations, he believes we need a wider lens as well.

‘Fifty-one per cent of Australians were born overseas or have a parent who was born overseas. 

'And everyone brings different cultures with them and lives with different cultures in this country. 

'Those different world views have an impact on healthcare and how people perceive their health and wellbeing,’ Michael says.

What it comes down to, he says, is that physiotherapists should want to know more than just what injury or ache has brought a patient to see them. 

They should also want to know who that person is so they can get them back to doing the things they love.

‘We want to recognise people for who they are, not who we think they are,’ Michael says.

It starts with students...

In addition to mandating that cultural safety training be included in all accredited physiotherapy programs at Australian universities and providing guidelines for embedding it into curricula, the APC requires overseas-trained physiotherapists to complete cultural safety training as part of their registration.

‘Based on our data at the Australian Physiotherapy Council, I’m pleased to say that every university is engaged with the guidelines that we’ve set out and each university is working in its own way to help improve the education of physios in Australia,’ Michael says. 

‘It’s a process that requires time, effort and building capability through both non-Indigenous and Indigenous staff.’

Blayne Arnold is an Aboriginal physiotherapist and a lecturer at Griffith University on Yugambeh/Kombumerri lands in Queensland.

Blayne Arnold.

A proud descendant of the Ngemba people in north-west New South Wales, he is currently completing a PhD examining culturally appropriate approaches to prepare physiotherapy students to work with Aboriginal and Torres Strait Islander peoples.

‘We didn’t want to presume that we knew what students were feeling so the first stage was to ask them how confident they were about working with First Nations Australians, followed by finding out what support they would need to feel better prepared,’ Blayne says.

Blayne surveyed and interviewed physiotherapy students from all years of the four-year degree program at Griffith. 

In many respects, his approach is an example of First Nations ways of knowing, doing and being in that he actually sat down with the students and consulted with them to figure out what they might need.

‘Students across all years recognised limitations in their preparedness to work with First Nations Australians.

'This was often accompanied by an acknowledgement that they are still developing their physiotherapy skills,’ Blayne says.

‘First- and second-year students suggested more content in the curriculum and opportunities to interact with Aboriginal and Torres Strait Islander peoples.

'Third- and fourth-year students thought that working with Aboriginal and Torres Strait Islander peoples in a clinical setting would help them understand what best practice looks like,’ Blayne says.

He says the next step will be getting the staff perspective—how prepared are academic staff to teach about working with Aboriginal and Torres Strait Islander peoples?

‘My first port of call is to talk to people who operate in this area,’ Blayne says.

Ultimately, he says, cultural safety training needs to be embedded in the physiotherapy curriculum from the very start rather than being taught as a single unit at some random point during the program.

...And extends to everyone else

Newly graduated physiotherapists may have more appreciation for providing culturally safe environments and practice than older physiotherapists who trained when there was less emphasis put on it.

Artist Nadia Rose.

‘The students and graduates coming through at the moment are a different generation and I find they generally understand more acutely the importance of culture driving who they are as individuals, who we are as a society, and how that relates to healthcare,’ Michael says.

‘Our first-year students here at Australian Catholic University become progressively more engaged with this work every year, possibly because of a larger influence of curriculum changes in secondary and primary education that promote a greater focus on Aboriginal and Torres Strait Islander peoples. 

'But when I talk to people who have been out in the profession for a bit longer, who have not had the benefit of this education, they don’t always quickly see why it’s important.’

He notes that some physiotherapists question the relevance of doing cultural safety training, seeing it as a burden that takes them away from running their business and seeing their patients. 

This is particularly the case if they perceive that Aboriginal and Torres Strait Islander people do not make up a significant part of their business.

Ultimately, Michael says, it’s up to all Australian physiotherapists to help put a stop to racism in healthcare and to support the creation of environments where Aboriginal and Torres Strait Islander people and communities can thrive with culturally appropriate care.

‘My worry is that if we don’t start to see some bolder leadership from people across our profession who hold positions of privilege in our profession and in the healthcare sector, we’re not going to see that change happen,’ he says.

‘Physiotherapists are a critical piece in addressing many non-communicable diseases that still disproportionately affect Aboriginal and Torres Strait Islander people. 

'The key to addressing this gap is for physiotherapists to be culturally responsive in their approaches to healthcare.’

Michael says that simply going off and completing a course on cultural safety isn’t enough. People need to spend time reflecting on what they learned and putting it into practice. 

An approach of cultural humility is best, a mindset that recognises that you can’t learn everything there is to know about another culture and understands that it may be different from your own.

‘A good practitioner will reflect and share knowledge through an in-service or discussions with their colleagues,’ he says. 

‘We need to be having open discussions in a safe place. It could be in the workplace or outside at an event or in other forums but it’s important that those conversations continue. 

'We need to provide space for that to happen and set dedicated time aside.’

The important thing to remember, he says, is that knowing how to provide culturally safe practice won’t just make you better at treating Aboriginal and Torres Strait Islander patients. It will make you a better practitioner, period.

‘Everyone comes with a different story, culture and world view, which will often challenge you. 

'Being a little uncomfortable is normal and something I embrace. 

'It is through these guiding principles that we grow together and recognise the strengths in each other and in ourselves, allowing us to be the best versions of who we can be.’

Cultural safety definition

Ahpra and the Aboriginal and Torres Strait Islander Health Strategy Group have provided the following principles and definition of cultural safety (Ahpra 2020).

Principles

The following principles inform the definition of cultural safety:
•    prioritising COAG’s goal to deliver healthcare free of racism supported by the National Aboriginal and Torres Strait Islander Health Plan 2013–2023
•    improved health service provision supported by the Safety and Quality Health Service Standards User Guide for Aboriginal and Torres Strait Islander Health
•    provision of a rights-based approach to healthcare supported by the United Nations Declaration on the Rights of Indigenous Peoples
•    ongoing commitment to learning, education and training.

Definition

Cultural safety is determined by Aboriginal and Torres Strait Islander individuals, families and communities.

Culturally safe practice is the ongoing critical reflection of health practitioner knowledge, skills, attitudes, practising behaviours and power differentials in delivering safe, accessible and responsive healthcare free of racism.

How to

To ensure culturally safe and respectful practice, health practitioners must:
•    acknowledge colonisation and systemic racism, social, cultural, behavioural and economic factors which impact individual and community health
•    acknowledge and address individual racism, their own biases, assumptions, stereotypes and prejudices and provide care that is holistic, free of bias and racism
•    recognise the importance of self-determined decision- making, partnership and collaboration in healthcare which is driven by the individual, family and community
•    foster a safe working environment through leadership to support the rights and dignity of Aboriginal and Torres Strait Islander people and colleagues.

Training resources

Cultural safety training is offered by a number of organisations including the APA. Both online and in- person training options are available.

Through its online professional development portal, the APA offers two courses to members:
•    Cultural Orientation Plan for Health Professionals (developed by the Combined Universities Centre for Rural Health in Western Australia) here
•    Australian Physiotherapy Council’s Cultural Safety Training for Physiotherapists (developed by the APC and the University of Melbourne) here.

Other courses include:
•    Indigenous Allied Health Australia Cultural Responsiveness Training here
•    Western Australian Centre for Rural Health (several courses available) here.

Other training resources can be found at:
•    State health departments
•    Aboriginal Community Controlled Health Organisations
•    Universities
•    Australian Indigenous HealthInfoNet here.

Quick links: 

• References

Artwork information

Empowerment

This artwork reflects the journey of a physiotherapist, guided by a supportive network of peers, mentors and diverse conversations. 

Each large circle represents an individual’s unique path, shaped by their experiences and continuous learning. 

These circles symbolise the knowledge gained through personal and professional growth, empowering the physiotherapist to provide better care. 

Emphasising curiosity and cultural understanding, especially of First Nations peoples, fosters a welcoming, safe environment where patients feel valued and culturally safe. 

This inclusive approach not only enhances patient care but also promotes individual and community wellbeing—empowering First Nations people to take charge of their health and support their loved ones.

Click here for more information.

>> Nadia Rose is a Gunditjmara woman living and working in south-west Victoria. She believes in the power of art and design to connect communities and convey powerful messages. Growing up surrounded by Aboriginal art and inspired by her father’s storytelling through painting, Nadia has dedicated her time to creative expression. She is committed to fostering a deeper understanding of Aboriginal culture through her work, promoting respect and appreciation for her heritage.