“In Unity and Respect”: Aboriginal Elders’ Reflections on Guiding Culturally Safe Care with Non-Indigenous Health Care Providers in a Mainstream Residential Care Community

1. Introduction

In English-speaking and colonised countries such as Australia, Canada, New Zealand, and the United States, Indigenous peoples are living longer but with a higher prevalence of dementia, and many with increased disability, increased food insecurity, psychological distress, and difficulty accessing and receiving culturally respectful and safe health care. These health inequities are modern-day effects of colonisation, reflecting how racism operates within the health sector and affects access to socioeconomic resources [1,2,3,4].

In Australia, the health care system, with differing approaches in states and territories, is recognized as complex and fragmented [5]. Aboriginal Community Controlled Health Organisations (ACCHOs) were initiated in 1971 to provide timely, comprehensive, sustained, place-based, and culturally grounded primary care to their communities. Currently, there are 148 ACCHOs across urban, regional and remote Australia [6]. Efforts continue to increase their number and capacity through Closing the Gap initiatives, but funding remains problematic. In its 2022 report to the Australian Government’s Department of the Treasury, the National Aboriginal Community Controlled Health Organisation (NACCHO) made 10 recommendations [7]. Recommendation 3 specified the need for adequate funding for the full implementation of the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan 2021–31. This need remains, with state and territory governments yet to commence any genuine transformative work, as documented in the independent review of Closing the Gap outcomes by the Coalition of Peaks [8]. Over 80 Aboriginal and Torres Strait Islander community-controlled organisations are represented by the Coalition of Peaks which partners with the Australian government to implement Closing the Gap initiatives to achieve health equality for Aboriginal and Torres Strait Islander peoples by 2030 [9].

Because of Australia’s under-resourced and constrained ACCHO sector, including the dearth of Aboriginal Registered and Enrolled Nurses in regional areas [10,11], older Aboriginal and Torres Strait Islander peoples needing health and dementia-related care frequently receive services from mainstream organisations and non-Indigenous care providers. These care providers may be unfamiliar with or unsure about providing care that is culturally respectful and safe [12]. Two additional NACCHO recommendations, numbers 2 and 10, address this, requesting greater accountability of mainstream service providers to deliver culturally safe services and greater accountability of mainstream service providers to employ Aboriginal and Torres Strait Islander people [7].

Education about culturally respectful and safe care for non-Indigenous health care providers in mainstream organisations must include partnerships with Aboriginal and Torres Strait Islander peoples [13]. These partnerships change the conversation from a focus on deficit to one on meaningful interactions, self-determination, and recognition of strengths, resilience and holistic approaches to ensure the spirit, voices, and culture of Aboriginal and Torres Strait Islander peoples drive their care [14]. Over the past three years, supported by federal funding, 12 Aboriginal Elders from Western Australia, Victoria, New South Wales, Queensland, and Tasmania have co-designed and continue to co-deliver a 12-week online unit, focused on culturally respectful and safe care, in the Wicking Centre’s Diploma of Dementia Care at the University of Tasmania. The unit is offered annually, with Elders holding weekly zoom yarning sessions with students, addressing questions on Discussion Boards, and participating as members of an Aboriginal marking team to provide students with authentic feedback on assessments the Elders have co-designed [14]. Content is grounded in four funded initiatives developed with and by Aboriginal peoples: the Good Spirit, Good Life quality-of-life tool for older Aboriginal peoples [15,16]; the online Caring for Spirit program [17,18]; Let’s CHAT (Community Health Approaches To) Dementia [19,20] and Aboriginal women learning on Country [21].

For broader outreach, the Elders interviewed each other to develop further content for five free and nationally available podcasts. A professional and trusted Media Specialist filmed the Elders as they yarned and travelled on different Aboriginal Nations. These videos were then shaped into 10-minute vodcasts to accompany the 16–24-minute podcasts. This digital approach provided a safe space for the Elders to share and speak freely [22]. It aligns with yarning circles—traditional Aboriginal ways to come together to learn, build respectful and caring relationships, and share and pass on cultural knowledge. In the podcasts and vodcasts, Elders’ knowledge is shared through storytelling, deep listening and yarning to illustrate authentic, culturally respectful and safe practices to educate the mainstream aged care sector and workforce.

The five initial podcasts focus on foundational concepts to welcome non-Indigenous staff and administrators into thinking about culturally respectful and safe care: ensuring connection to Country for Aboriginal and Torres Strait Islander peoples, facilitating cultural safety in aged and dementia care, understanding intergenerational trauma and the need for trauma-based care, how traditional medicine and bush foods can complement Western-oriented approaches to care, and ensuring culturally safe end-of-life care/entering the Dreaming. The complementary vodcasts document the importance of Country and how connection to Country and strong spirit can be established and maintained in mainstream residential care communities.

The aim of this study was to pilot the educational podcast-vodcast approach at a mainstream residential care community to provide non-Aboriginal staff and administrators with valuable opportunities to interact with and learn from Aboriginal Elders, as a means to initiate changes needed to ensure culturally respectful and safe care for Aboriginal and Torres Strait Islander peoples with dementia. This paper presents the Elders’ reflections following their initial (baseline) visit to the residential care community, prior to the release of the podcasts and vodcasts, and subsequent follow-up visit.

2. Materials and Methods

Elders piloted the educational podcast-vodcast approach with staff at a mainstream residential care community in rural Trouwerner/Lutruwita (Tasmania), a southern island state of Australia. Elders travelled to the residential care community and met with staff over two days to yarn and introduce the project. The podcasts and vodcasts were then available to staff on a website for six weeks. Following this period, the Elders returned to yarn with staff about their experiences.

The residential care community had 67 beds, with 73 Independent and Supporting Living Units close by. The Director of Care stated there were no current Aboriginal or Torres Strait Islander residents. There were 11 full-time staff, 93 part-time staff, and 34 casual staff employed in a diverse range of positions. Fifteen staff identified as Aboriginal and/or Torres Strait Islander.

Given the rural location of the residential care community, most Elders flew to a city in Tasmania and then drove 3 hours to the location. Two Elders lived nearby and had visited the care community some weeks earlier to meet with the Director of Care and CEO of the Board, and to introduce the project to staff and distribute materials. Elders spent four days in the area: two days (Saturday, Sunday) to appreciate and learn about the region, and then two days (Monday, Tuesday) at the residential care community. The care community visit officially began with a traditional Smoking Ceremony, held at lunchtime on Monday to enable staff and residents to participate or observe. With permission from the Director of Care, the Elder conducting the Smoking Ceremony was able to remove part of a garden to create a fire hearth, embedding the fire in the earth, an important part of the ceremony. This Elder was then invited to explain the Ceremony to residents and staff. For the remainder of their visit, Elders yarned with staff, individually and in small groups, moving freely about the centre. After returning to the city on Tuesday afternoon, the Elders met to yarn and de-brief. This 60-minute yarning session was held at the University and audio-recorded. A transcript of the session was developed, coded and thematically analysed by one author (LG), and then reviewed and discussed by all Aboriginal authors to ensure the interpretations were accurate.

Ethics approval for the project was received from the Human Research Ethics Committee at the University of Tasmania (H29817).

3. Results

Six themes were identified: (1) Importance of truth telling, (2) Value of staff interest, (3) Impact of the Smoking Ceremony, (4) Appreciation of the care environment; (5) Lack of Acknowledgement and understanding, and (6) Contribution of an Elder-in-Residence program. These themes are reflected in the Elders’ detailed comments. Elders were not identified to preserve confidentiality due to the small number in the group.

3.1. Theme 1: Importance of Truth Telling

Elders valued the preparation for the two-day visit:

“I think it was important that local Aboriginal people were engaging with the facility prior—already establishing a relationship there and looking at how senior management can support us. I think that’s always a way to go—engaging everybody at all different levels to make sure that everyone is on the same page.”

“For me, it started out with anticipation and mixed feelings …but it’s about just being positive and looking for that outcome that’s going to benefit everyone that’s involved.”

Elders then focused on the importance of truth telling in discussions with staff for them to understand culturally safe care:

‘We need to be truthful, honest, and direct in our stories.”

“We need to get the staff engaged in what we want, cultural safety in the facility. We need to be truthful. I reflected on my own experience before about making people safe and I think it’s important that we all understand why that is important in this type of work. Talking to the staff about who we are as Aboriginal people, where we come from, and about our lives and our history. It’s important for the staff to know about our Aboriginal history, get an understanding of us, and what we went through when colonisation started, and even years after. If they can’t understand our history, I don’t think they’re going to be understanding of what cultural safety is. A lot of people don’t like people like myself talking about the atrocities of our history, but it’s all about truth telling…Stolen Generations, our kids taken away, put into institutions and treated like dirt. We carry these things in our heart … and it still bothers us.”

“I’ve always said and believed that if you don’t tell the truth, you’re pandering to the white people.”

“I think it’s a big learning curve for all this mob. They don’t have that history and so it’s like we are one of the first to really confront them.”

3.2. Theme 2: Value of Staff and Resident Interest

Elders valued the positive interest shown by staff and residents:

“I think people were intrigued to see us all as a group together …to see all these Black faces…that was something that was accepted very well.”

“That we were all there together, that was a big surprise to them, but it was a good thing to go there as a group. I guess for a lot of the residents, it would have been the first time they saw a mob of us together and I think that was very interesting for them.”

“They probably didn’t expect to see a big group of us together, but I think that they really liked it and they really engaged and we kind of felt very welcome.”

“Some people will sit there with straight faces and not say a word, but we found most staff there very engaging and wanting to know more about what we were there for.”

“Having a conversation with [administrators] last night over dinner just reassures me that people are willing to work towards partnerships and relationships that are going to make aged care a place of choice and a place of safety and a place where families can visit their residents without any fear, harm or anything else that would impact on their lives while they are going through the final stages of their lives.”

3.3. Theme 3: Impact of the Smoking Ceremony

Elders commented on the educational impact of the Smoking Ceremony and the support of administrators:

“I do think that was something that was quite accepted. A lot of the residents wanted to watch. The CEO and Director of Care were very supportive. They both stood out with us around the fire, engaging. That for the residents was very, very powerful—I think because it meant that from the top down, they were supportive of what we were putting in place.”

“I think the Smoking Ceremony set a bit of a tone for everybody, the interest in it and there was a lot of people watching that and then asking questions about what it meant so people were genuinely interested.”

“First time they’re learning about our culture.”

3.4. Theme 4: Appreciation of the Care Environment

Elders were impressed with the positive environment and staff-resident relationships:

“Staff seem to be hands-on …It’s more a warm, relaxing feel and you could see that in both the residents and the staff.”

“I’ve been involved in nursing aged care before, but I think that was one of the best I’ve seen. There was a calmness there …a good relationship between the staff and the residents... I just felt that it was a lovely facility and they’re just very willing to learn with us.”

3.5. Theme 5: Lack of Acknowledgement and Understanding

Elders expressed concern at the omission of cultural ways to acknowledge Aboriginal sovereignty and welcome Aboriginal staff, residents, families and communities:

“When we walked toward the place, there was no Aboriginal flag outside. There is certainly no acknowledgement of the land that the community is on. It’s not very welcoming to Aboriginal people at all.”

“Lots of photos celebrating colonial times, not our culture.”

“I tried to picture myself here—it was just that sort of sterile, clinical kind of environment. I would feel very culturally isolated living here.”

Concerns about possible racist attitudes from some staff were verified:

“I had a little bit of a concern walking into a non-Indigenous or mainstream organisation. I was a bit worried that we may get a few little snide racist comments or looks from people. But not at all. It really surprised me. There was one lady … a little bit of a vibe …sort of brushed me off straight away. But everyone else was so open and welcome and wanted to hear what we had to say. So that really took me back a little in a good way.”

“There’s only one staff person that I picked up on as well. She’s busy going around. There was no smile, nothing. She just went about her business. And I knew she would not engage with us or agree to participate.”

“One of the nurses had studied a unit on Aboriginal history. She said it was boring. That really hit me. But I saw the change in her spirit when we started talking. She took on board that we were there to help her through some of these questions she may have.”

The importance of the podcast-vodcast focus on culturally safe care was clear:

“What is absolutely key is for non-Indigenous staff to understand what cultural safety is. When we were sitting with a couple of the nurses there and we’re saying, you know, “This place isn’t safe for our people.” I could see them sort of thinking, “Well, you know, the doors are locked and the windows. There’s no trip hazards.” I don’t think they really—they don’t understand the term, what cultural safety really is. So that’s up to us. Through these podcasts, hopefully they’ll learn that, what that term really means.”

But that’s part of their learning too, isn’t it? They don’t know about those sort of things unless they engage with us and know what we’re on about. Understanding what it means to provide culturally-informed, trauma-informed care, because for a lot of our mob, there could be triggers, and if they don’t know what those triggers are, it’s not going to be culturally safe.”

“We’ve also got to be mindful of trauma-informed care for Aboriginal staff, as well as the residents.”

Some interactions raised pain and discomfort:

“One old bloke came and he stopped and he was choked up for some reason, and he ended up telling us a story about a grave where a skeleton was laid out …but it was something that a white man may do, not an Aboriginal burial …obviously a white person wanting to get rid of something.”

This led to a lengthy reflection on traditional burial customs and traumatic “Sunday hunts” of Aboriginal people, with consolation from another Elder:

“Sometimes it’s not good for us to talk about these sorts of things in company.”

A further discussion ensued on the need for non-Aboriginal people to understand and be honest about Australia’s colonial history and work in partnership with Aboriginal and Torres Strait Islander peoples to effect needed change:

“Are white people doing exactly the same as us, trying to make change?”

“That’s what’s missing …they’re not telling their truth. Because when you look at what oppression, internalised oppression is about, when we internalise the traumas we have, we take it out on our own people first because it seems safer to do that. This is my big question for non-Aboriginal people … to get into their own history. Because when you come together in that oppression stuff, each camp got to do their own thing first, heal in their own camp first, before you can come together to heal.”

“Do you think white Australians, from that time of colonisation and all the way through, will tell the truth of what they perpetuated on Aboriginal people?”

“Yes and no. It depends on what groups you’re talking to. There’s going to always be resistance, so we have to work with those who are ready and willing to make that transition. But non-Aboriginal people have to do their own work just like we’re doing. It comes back to that cultural labour—working together in unity and respect.”

3.6. Theme 6: Contribution of Establishing an Elder-in-Residence Program

Elders reflected on the impact of establishing an Elder-in-Residence program at this, and any mainstream residential care community:

“I think the Elder-in-Residence role will certainly be significant in gently confronting issues… coming from where people are in their understanding and then bringing them forward to get that cultural understanding and immerse them in activities that actually make sense. So, they use their senses to understand, because they feel it more so than just hearing it. We bring them along with us. We bring them new understandings and new life to where we’re going.”

“…Where things could be more obvious and open to having Aboriginal people come in and feel comfortable in that space—so that the space is culturally safe. As soon as they walk in the door, they can see the things that make them feel comfortable that they’re not just going into a non-Aboriginal institution where some of them may have been institutionalised in earlier years [as at Missions]. It actually takes away that trauma in some respects so that it is a place that they want to be and can ease into a different lifestyle in a residence like that.”

“We all can contribute to some of the activities that might happen there, to actually engage not only Aboriginal people but non-Aboriginal people so that they are learning and getting an education at the same time without realising it; they’re just having fun which is what we’re all about.”

“And it would help in building relationships and partnerships with ACCHOs, like with Booroongen Djugun” (an ACCHO in New South Wales, a state on the Australian mainland, where one of the Elders worked).

As the yarning session ended, Elders planned to ask the Director of Care for more structured time when they returned to meet with staff to listen to their experiences:

“It would be wonderful to have more one-on-one time with a group of staff, for them to meet us all personally and have a yarn about the project. If we could potentially get a whole group together to yarn.”

An Elder also shared a personal experience from being part of this Elder Group. He reflected on being in Year 8 and asked to write about what he wanted to be when he grew up, for a project in an English class. He had said he wanted to travel around Australia. He continued:

“To meet Elders, interview them, talk to them, find out about their language, their way of life, their tribe, everything …and I thought I’m here now, almost 40 years later, and I’m doing it.”

4. Discussion

This paper identified six themes from Elders’ reflections following their initial visit to a mainstream residential care community in rural Tasmania. The Elders’ visit was to interest staff in listening to a series of Elder-developed podcasts and watching complementary vodcasts focused on culturally safe care for Aboriginal and Torres Strait Islander peoples with dementia. The themes raised both positive and challenging issues, the latter highlighting the residential care community’s lack of Acknowledgement of Aboriginal sovereignty and cultural ways of welcoming and sustaining Aboriginal staff and residents, and their families and communities.

One might conclude that as there were no Aboriginal or Torres Strait Islander residents identified by staff in this care community, the lack of acknowledgement of Aboriginal culture was not a problem. This would be an erroneous and discriminatory conclusion. The Australian government has established national best practice guidelines for asking all people about their identification as Aboriginal and/or from the Torres Strait Islands when they receive health care, including a move into a mainstream residential care community [23]. This identification is important to ensure that the care provided is culturally respectful and safe and to counteract the impact of under-identification. Under-identification remains a significant issue across Australia, affecting the accuracy of national statistics, health data, and access to specialized services, particularly for older people, and adversely affecting Close the Gap initiatives [24,25]. Under-identification is a particular issue in Tasmania due to the state’s history of genocide and continuing associated and intergenerational racism, with fear, shame, and distrust that has forced many to hide their ancestry [26]. Many feel that Australia as a nation has not yet acknowledged and owned the atrocities that were committed in the frontier wars against Aboriginal and Torres Strait Islander peoples.

The government’s identification guidelines aim to address the documented issues of staff not being trained or aware of the importance of asking the question, being reluctant to ask the question, not providing privacy when asking the question, being unsure how to react if people refuse to answer the question, and/or not maintaining adequate records or data management systems. At the rural mainstream residential care community which is the focus of this paper, staff and administrators appeared unaware of Aboriginal residents in their care or where records were to document this. In a walk around the care community, a local Aboriginal Elder identified 23 residents (34%) who were known to identify as Aboriginal. It is interesting to consider this number in light of the Elders’ recognition of the interest of many residents in the Elders’ presence and the Smoking Ceremony. Non-Aboriginal staff need to understand that non-identification by Aboriginal residents does not necessarily equate to not needing or wanting to live in a culturally welcoming environment or to receive culturally safe care. This is a key issue to address as Tasmania has no Aboriginal Community Controlled residential care centres. Thus, any Aboriginal or Torres Strait Islander adult needing residential care in Tasmania must move into a mainstream care community. Mainstream care communities that do not welcome Aboriginal and Torres Strait Islander peoples—tangibly and through culturally safe care—continue to perpetuate racism and inequitable health care [1,2,3,4].

The importance of non-Aboriginal staff in mainstream care communities being able to provide strengths-based, holistic and culturally safe care has been documented [5]. Culturally safe care is reflected in staff understanding and implementing the Good Spirit, Good Life assessment [15,16] when older Aboriginal people move into a residential care community. The Good Spirit, Good Life assessment is accompanied by a training guide and recommendations informed by Aboriginal Elders and is advocated by the Australian Government’s Aged Care Quality and Safety Commission for use nation-wide [27].

Elders’ reflections in the current study suggested that most staff working in the residential care community cared about the residents, were willing to learn more, and were supported by the Director of Care and the CEO of the Board. The Elders’ return visit, after staff have listened to the podcasts and watched the vodcasts, will provide insight into the impact of this digital learning initiative and the opportunity to yarn with Elders about culturally safe care. Such insights will be valuable in establishing the role of an Elder-in-Residence program to facilitate reciprocal visits between staff at mainstream and ACCHO communities. This is an important strategy to work in partnership to sustain culturally safe care and optimise the health, wellbeing and quality of life of Aboriginal and Torres Strait Islander adults in mainstream residential care.

5. Conclusions

Elders’ experiences from their initial visit to a rural mainstream residential care community confirmed the need for education about culturally safe care for Aboriginal residents and how to implement such care. Aboriginal residents appeared unknown to staff. The environment was calm and supportive but not culturally welcoming to Aboriginal residents and staff. Elders’ reflections provided valuable insight into the need for their innovative series of podcasts and complementary vodcasts focused on culturally safe care, and important baseline data from which to measure its impact.