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Culturally Safe Healthcare: Addressing Racism and Rebuilding Trust with guest Dr Shingisai Chando
00:39:12
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- [00:01]
A
Welcome to the New Books Network. The Cultural Competence Collective comes to you from Unceded Gadigal country at the University of Sydney. This country is a place of deep history and connection and I honour the enduring connection of the Gadigal people to this land. I would like to pay my respects to elders past, present and future, who have always had and will continue to have custodianship of this beautiful land.
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B
Who is at the table when decisions are being made about how to support people, or if even a conversation about how to support people is occurring? We continue to be quite dismissive of people who experience racism. Ensuring that we have the right people at the table continues to be a real challenge.
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A
Welcome to today's episode of the Cultural Competence Collective. My name is Pooja Biswas and I'm from the National Centre for Cultural Competence here on Unceded Gadigal Country. In this episode, we'll be joined by Dr. Shingi Chando. Dr. Shingi Chando is a research fellow at the Post Centre for Indigenous Health at the University of Sydney. Her research in health services falls under two streams, Aboriginal and Torres Strait Islander child health, where she seeks to improve the integration of Aboriginal and Torres Strait of family experiences into health services design and delivery and racism in health, specifically its impact on workforce and health services delivery. Her research interrogates and seeks to disrupt conventions of power and control within health systems and health services delivery and challenges siloed approaches to promoting inclusion in pursuits of health system resilience. Hi, Xingi, it's so wonderful to be able to speak to you today. To start us off, what does cultural competence mean to you?
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B
I think the term cultural competence, gosh, it's, it's, it's so loaded, isn't it? The first time I came across the term, I was in the United States and at the time I was working for a nursing research department within a large hospital in Dallas, Texas. And at the time we were thinking about cultural competence because there was a massive sort of nursing recruitment drive in the US and they were recruiting nurses. This particular hospital was recruiting nurses directly from the Philippines. Interestingly enough, the conversation was really about how do we support the Filipino nurses to become culturally competent working, working in the United States. And look, yeah, there are aspects of that which is absolutely true. Right. So they wouldn't have been familiar with African American culture or even any of sort of Native American culture as well. So there is that aspect. But in fact, the cultural competency training wasn't focused on that at all. It was more about dominant culture and understanding dominant Culture, there was more of an acculturation kind of approach to it, you know, so, yeah, working out how to support these nurses so that they could assimilate to the dominant culture. Right. And that was my first experience with, with cultural competency. And in fact we used to use terms like cultural sensitivity then as well. Then there was also the conversation about integration. So kind of like you're saying in an assimilation, but it was more how do we support existing American nurses in working with Filipino nurses. So we tried to create spaces where there would be an exchange, but it was really absurd because it was part of orientations. It was like maybe two hours of the orientation session and if people were supposed to come out culturally competent and generally not my preferred term in terms of working with cultures and helping people develop skills to operate across cultures.
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A
So, yeah, thank you for providing that context. And it highlights how often, you know, lip service is paid by organizations, you know, to these concepts, as though, you know, a single two hour exposure is, you know, going to significantly change things. One of the things we emphasize at the national center for Cultural Competence is that this is a lifelong journey and that we have to develop those critical self reflection skills to be able to identify ourselves as cultural beings and, and then, you know, starting from there, being able to appreciate where other people are coming from.
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B
Absolutely.
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A
I'm also very curious. So you grew up in Zimbabwe, so how did your upbringing shape your worldview?
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B
Yeah, oh gosh. So I grew up really privileged actually. But it was, it was, it was also quite interesting because while I grew up privileged, it wasn't necessarily the case for everyone in my family. I was quite lucky because I have a dad who community mattered to him and still matters to him quite a lot. And for him, he used to always use words, you know, like legacy. And I remember at 16, he gave me just as, you know, haphazardly said, oh, here are the seven Habits of Highly Effective People by Stephen Covey. Can you just read this? And I remember being the only 16 year old in my, among my cohort of friends who we had this book and. But I was really into it and have really great conversations with my dad. And turns out that my grandfather had been really involved in community development work and was really great at mobilizing communities. And both my grandfather and my grandma were really, really passionate about education access and so they worked really hard with communities to improve access to education. And dad always say, you know, your grandfather, he, you know, he didn't read or he didn't, but he was, he was a great Connector. He knew how to find the information that he needed to, to get things done and he knew how to connect with people and communities. And I grew up also just watching my grandparents. I remember them mobilizing the community to make bricks because, you know, that's what you do, that's what you did back then and people are still doing it now. They make their own bricks and they, they built their own school and they just didn't want to wait for the government to do it and they were tired of their kids walking long distances.
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A
That's so empowering for the community to be able to do that.
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B
Absolutely.
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A
Rather than being reliant.
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B
Yeah, yeah. And look, it's, it's, you know, a challenge in these countries as well. It's, it's a failure of government to be able to provide that. But I think they were incredible trailblazers like my grandparents and many, so many others who took it upon themselves to say, hey, you know what, what can we do and how can we contrib? My grandmother taught at that school for a while for free without pay. But it became such an important part of the community. So. Yeah, so watching, you know, having grandparents and parents who are, who are community minded that way was really important and impactful for me. My view, I guess, of the world was always that of participation rather than sitting back and watching. For me it's about genuine connections wherever I am.
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A
I think your dad must be, you know, really proud because you really are carrying on the legacy of your family, you know, in, in community development and, and service and empowerment.
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B
Yeah, yeah.
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A
And you know, you're involved in education as well. So this is actually, it's really lovely to hear that sort of generational thing and.
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B
Yeah, that's very true.
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A
And, and well done too for continuing it, that important work.
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B
Thank you.
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A
So, you know, your current work that you're doing right now looks at racism in the workplace, particularly in the healthcare setting, and the responsibility that organizations have to support people who have experienced racism at work. What are some of the ways that you think organizations can do this effectively?
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B
There are a number of different ways. What I'm particularly passionate about in my work is elevating the voices of people who have the experience. We are doing a pretty decent job actually in Australia in terms of campaigning, I guess, against anti racism. And I think the way I think about it is probably comparatively across the globe and the efforts in this space. I think in Australia we are having these conversations and what I find though is that it's almost that the conversations are repeated that it's almost the same conversation that we've been having for generations. And I can say this with quite a bit of authority actually, given some of the work that we've been doing. It's been decades. It's the same conversation. It's the same conversation and it's across all the disciplines in health, particularly around first nations and even for migrant communities who are working here. They're asking for the same things, they're saying the same things that they were saying, you know, in 1960s. And it's the same conversation.
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A
Could you elaborate on that conversation for us?
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B
Yeah. And it's really about that organizations continue to focus, particularly around education. There is a big focus on let's educate everyone in the hope that we can make them more culturally competent. While that's important. And again, within the evidence and what we're seeing is that that remains a really critical component of anti racism campaigns. However, the person who is the target of a racism incident continues to feel unsupported and that has, hasn't changed. And so I guess the conversations that we need to be having more in organizations is that why is that the case? Are organizations doing a really poor job of listening? What is it within the structures, what are those underlying elements within organizations that are making it difficult for them to support people who are the targets of racism? I think it's definitely an ongoing conversation and also the question around who is at the table when decisions are being made about how to support people or if even a conversation about how to support people is occurring. We continue to be quite dismissive of people who experience racism.
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A
So is the implication there that as you say, you know who is at the table, that whoever tends to be at the table is not necessarily representative of the diversity of the, of the people in the rest of the organization. And therefore there is sort of either a willful or an unknowing lack of understanding or appreciation of that or what is your view that is the sticking point, that that sort of keeps, you know, keeps these organizations from either understanding or if they understand them, from acting.
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B
Yeah. So representation is again, continues to be a real challenge, ensuring that we have the right people at the table. But within that often there is the tokenism as well. So it might be that there is a Diversity and Inclusion committee. What we're finding is that often those task forces are for a very short period of time. So you have a Diversity and Inclusion committee to complete a project and once that project is completed, then the group is disbanded. And I think in health it's Particularly challenging because the people who are at the front lines of experiencing the racism are often frontline staff. So it would be your doctors, it would be your nurses, but within that also there would be additional staff. So it might be staff who are cleaning patient rooms. So there's a lot of movement in these groups. So I think it's quite difficult even for organizations to have a group that just remains so or can be there for long enough to see change. And that's understandable. But there needs to be a commitment from organizations to maintain those groups regardless. So you have to find a way to create a structure in which you're hearing from the voices of people that you need to hear from. So with that tokenism that I mentioned before, the challenge is often then whether you have people who are in these groups who have actual lived experience of racism within a healthcare setting in Australia. Identifying those people is challenging and continues to be challenging because we don't really have mechanisms for reporting. The culture within a number of organizations also continues to be one of fear. People are afraid, they're afraid to speak up.
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A
That there would be, you know, professional and. Or personal consequences for speaking up.
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B
Exactly.
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A
And are there any sort of consequences that you've witnessed or heard about people having gone through?
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B
Not directly. So I know from the literature, yes, there are numerous accounts and numerous stories that people tell. But if I were, you know, talking from my own sort of personal experience, from a person who's had some kind of repercussion, often what happens, happens. And I'm quite privy to conversations in this space just because of my work. I do have a clinical background as well. But within the Zimbabwean community here in Australia, there are quite a few nurses, and that's probably across a number of migrant communities as well. So I am quite privy to conversations in those groups and what people often say is that they either they don't say anything, they are afraid to say anything, and perhaps in a number of cases, and also I guess thinking about some of the organizations that we've worked with in a number of cases, it is a perception that I can't say more of a perception because I really don't know. But it does seem to be a perception that if you do report that there is likely some repercussions. And I think maybe the conversation is really one about power as well. Right. And how power is distributed. Because if people feel disempowered in their roles, I guess the question is if they have an incident, are they likely to. To report so. And when I talk about Being disempowered. You think about whether, when a person is the only first nations or individual from a culturally and racially marginalized population, if they're the only person in their whole ward, you know, what is their perception of whether they feel like, you know, if they report an incident, whether they will be supported. It's, it's those kinds of things, I think, that impact on people's decisions to report and ultimately what happens in terms of support from the perspective of the organization.
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A
And I think that also speaks to the fact, you know, the fear of reporting, which is something that I've also heard of in my community among Indians, as, you know, a lot of whom are in the health sector. And I have heard this sort of similar fear. And I think it's the weight of, and sort of the sense of authority behind some of that racism and that sense of power. And so one does feel disempowered in comparison because it's just one person against what feels like a tidal wave of policies or willful knowing indifference and that sort of, that lack of understanding and empathy. And so the feeling of, well, you know, even if I was to speak up, I. What would change? And I would only have made myself vulnerable.
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B
Yeah.
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A
And you also mentioned tokenism, and I find that really, really interesting. And so have you come across this frequently in your work or in your research where, you know, there is sort of, you know, diversity, equity and inclusion initiatives in which, for example, the one person of color is sort of appointed or the one indigenous person and you know, it's the sort of bare minimum thing that, oh, well, we've got someone, and then somehow they're supposed to represent everyone in the community or people of color and which of course lacks that nuance because it's not the genuine diversity of having, you know, several people instead of just one. So what are some of those examples and what have the consequences been?
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B
I do have an example, actually. I was aware of a, a committee that had been set up and, and there were people who were speaking into that committee and a few people within that committee didn't actually have experiences with racism. And while they identified as being from culturally and racially marginalized populations because they didn't have those experiences and they were quite confident. And this is a real challenge and a real problem, again with power, because again, we think about structures of power and how privileged people then can tend to be the people who end up in power anyway, regardless of race. Maybe not say regardless of race, but taking race out of the equation, it's still the same. And so you have these people who are probably like myself, who have been privileged and have now assumed these positions of power and so are, you know, are in a position to where they can be included in this particular type of group. And again, also thinking about the structure of, of these groups. So within a health setting, people who are included in this group or who participate are often people who have the time to do so. So your regular nurse who, you know is managing 8 hour or 12 hour shift, might be too tired and is probably not going to attend all the sessions for this kind of thing. So you end up with people in pretty senior roles who are part of these groups. So in this particular instance there was one who, a senior person, but very vocal. Essentially, because they were so vocal, it meant that the voice of everybody else was quite diminished. And they, you know, continued to speak about their experience and how great their experience had been. But that's not everybody's story. So then you start to think about what is the impact of, of that on being able to progress an agenda that is, you know, very supportive of people who have experiences with racism. And in, in this case, it took people who were part of this group who were from the dominant group population, it took them as allies and people who had a sense and had an understanding of what was actually happening to actually speak up. And so it becomes sort of this power struggle, Right, between the culturally and racially marginalized person who has quite a bit of power within a specific space and is not really using that power to, to support the rest of the population who essentially need them to be that voice. Yeah, so there was some friction there and it was quite challenging. And it then ends up being a situation where they're almost different groups within a group. And that happens quite often when you start to see these groups disintegrate or, you know, disband because people feel that the dominant voice is not representative of everybody in that group and their experience. And they don't feel like they're empowered enough to, to say something or to speak against the person whose opinions seem to be the loudest.
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A
There seems to be a lack of understanding of lived experiences of the people who are experiencing racism. What are some of the strategies or methods that you can think of or recommend for organizations and individuals to deal with this or to try to combat it?
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B
Being proactive? I think from the perspective of the organization, recognizing that this is an issue that requires the organization being very intentional with its policies and its structures around organizations or diversity and inclusion committees, if that's the direction that they take. And I say this because we have done some work in health in general around consumer involvement and that's been a massive thing. And again, there are challenges there with representation, making sure that there is representation from consumers, people with lived experience. So we see it across other areas, whether it's disease specific. So if it's cancer, you want people with lived experience. We're not doing perfectly clearly in those areas either, but it's very specific and there is a structure within health or a set of policies that supports that piece of work. So I think it's about recognizing that, you know, when we are trying to address racism, that this is a very important part of trying to address racism within an organization. One of the areas where we are still challenged is recognizing the fact that racism is a very contextual phenomenon. So location, place, place based interventions matter. In saying that it means that if a health setting has recognized that they need to implement some anti racism initiatives which really should be happening across all institutions because racism occurs, it's everywhere. But for each organization to recognize that they need to be including people with lived experience. But that can only occur if those organizations have put in place mechanisms through which people can report experiences but also put in place a culture or in an. Or have developed an environment in which people are not afraid to speak up.
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A
Where they feel safe.
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B
Exactly. And people feel safe enough to speak up without any sort of repercussions.
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A
And in some ways it must be getting more difficult because of late there has been an increase in anti immigrant sentiment in a lot of sort of western countries. Xenophobia and sort of more outspoken kind of, you know, right wing racist sort of dialogue going on here in Australia. But also, for example, with what's happening in America where you know, diversity, equity and inclusion, DEI is being actively, actively destroyed in the last several years. Do you think those things have impacted situation here in Australia or has that not really been the case?
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B
Oh, it definitely has. There is a piece of work that we're doing now in these qualitative studies. First nations healthcare staff are, are saying the same thing essentially that they would like to see more conversations about racism occurring within their organizations. And they're saying people aren't talking about it. There is this real sense again, it's a fear, isn't it? A real sense of fear. They're sort of then calling it out and essentially asking organizations. It's a call to action to say create environments in which people, people have these conversations. It should be a conversation that people can have openly without Fear. And however, I recognize that it is difficult to navigate those kinds of conversations, particularly when organizations are concerned about cohesion. So it is, you know, it is quite difficult.
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A
And then the onus is often put on the one or the ones who are perceived as different to change things and not the people who are actually.
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B
Yeah, yeah, yeah, yeah. And organizations tend to take that route of shifting responsibility to the people who have the experience of racism. So again, we. We know that from the work that we do that people report feeling that they were left to deal with it on their own. Often people do report to their man, directly to their managers if an incident occurs. However, after that, the actions after that vary so. So widely. Some managers take it upon themselves and are responsive, but the majority are not. And often it is then put back on that individual to. To decide. And that's really difficult because if you think a person might have, you know, worked up the courage to go and report that they've had this experience, and it might be that they've tried to do it confidentially, but often these things happen when others. When they're witnesses. Right. They're bystanders. And it's. It's even more painful. And we've seen this in. Where people say, everyone was in the room when this happened. All my colleagues were in the room when this happened, and no one else did anything.
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A
So that culture of silence contributes to the lack of safety, the feeling of safety.
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B
Absolutely, absolutely. And then, so you. You have, you know, you then have that person then like I said, take, you know, work up the courage to then, despite that, what's happened, go and tell their manager. And then if the manager is not responsive and puts the onus back on them, that person still has to go back to that environment in which this trauma has occurred. It's really challenging for individuals who have this experience to work out how they fit in and where they belong within an organization. From the organization's perspective, it's hard to know whether managers are not responding because they're afraid as well. You know, especially if no one else did anything, if no one else reported it, maybe they're concerned and their priority is, you know, that they just want to maintain cohesion within a team, particularly in health.
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A
Health.
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B
They might say, oh, look, you know, we don't want something that is disruptive towards the ward because we want people to continue to come to work, and we don't want to create a toxic environment. And so they might perceive, you know, their intervention as exacerbating a situation rather than actually supporting teamwork or the team coming together and working through an issue together.
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A
So kind of they just kind of want to keep the cut rolling.
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B
Exactly.
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A
Even if the cut's broken in many places.
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B
Yeah, yeah, keep going. And some people have talked about assisting managers to develop skills and conflict resolution and, you know, the organization's responsibility in making sure that managers know how to do that in all this, sort of, you know, developing the skills to work across cultures. There, there is that very specific skills in helping people, people manage conflict. And I think it goes back to your point about how what is happening externally is impacting, you know, environments within organizations, and particularly in health. We think of them, really, they are social institutions. Right. So they are often a reflection of whatever is happening in society. It is an environment where we have to really think about, or organizations have to really think about how they are supporting people to manage those kinds of challenges that are externally influenced. Right. There is such a transient population as well, that you have through patients, and so you just never know. You never know who's going to walk through the door, what their experience is and how they're going to treat staff. So staff are not only getting it from other staff members, but they might also be getting it from patients. And it's a pretty challenging, challenging environment.
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A
You know, you've been talking quite a lot about the healthcare system and you've done research on funding decisions for child health services. What role does cultural competence play in shaping those funding decisions?
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B
Again, it goes back to how organisations are preparing their staff to work across cultures. With that piece of work that we did around funding decisions, one of the themes was really around how, particularly first nations, how they were experiencing being part of a committee or a team that was responsible for funding child health services. Aboriginal and Torres Strait Islander child health services and the experiences they described were quite harrowing. One person, I remember they were particularly concerned that they had been included in this statewide group that was supporting funding for Aboriginal and Torres Strait Islander child health services across the state, based on the fact that they were a First nations person with experience working across health services, but also with experience working directly with communities. And yet at almost every single meeting, they left very frustrated because they were essentially asking for the same things repeating themselves over and over again. And yet their supposed expertise were not taken seriously at all. And they would have to go back to the community and explain to them why they hadn't received the funding that they had requested. And communities would, you know, would say to them, but we've been asking for the same thing. We don't want what they're offering us and what they're giving us. But we've been asking for the same thing over and over again and that's not what we're being given.
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A
It's the sort of blitz link of the voice of the person. But then perhaps also this, you know, as we're talking about kind of like in maybe an anti diversity or anti diversity and inclusion thing where people are like, well, you know, well, you're just here for that reason and so therefore we don't really need to listen to you and you're not as much of an expert as we are. Is it. Is there that or what. What is the.
- [31:27]
B
It's very hard to. Yeah, it's very hard to know because, you know, but this person was quite clear that, look, I've been. I've been invited into this committee because of my skills and because of my connection to community, and yet all my comments and my recommendations are being dismissed. And he. And he'd been part of this committee or this group for years and his frustration was the, you know, the communities are asking for these specific things and I keep bringing those forward to this committee and I've been doing it for years. And that's not what they're receiving funding for, even though that's what they're asking. So it was a complete, almost a complete dismissal of him and his expertise.
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A
That's actually quite horrifying to hear. It is, it is.
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B
Especially at that level. Yeah, especially at that level.
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A
That must come with that over time.
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B
Oh, yeah.
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A
You know, and that invisibility and the lack of the acknowledgement of a person's presence, their voice and often entire community. And it also shows how entrenched that behavior is of ignoring diverse voices, first nations voices and so on. That's. That's actually, you know, quite a terrible thing. Are there any other similar stories or
- [32:45]
B
for that piece of work? There were first nations participants, but there were also some non indigenous participants who had worked in community for. For years, essentially all throughout their career. And it was quite similar even for them, which I thought was quite interesting, was. Although they would have been perceived as, you know, the typical embodiment of power in Australian society because they were privileging the voices of, you know, minority populations, they essentially were dismissed as well, or their recommendations when it came to supporting the communities that they were working with, those recommendations were often dismissed. And so again, it goes back to the conversation around power and particularly when it comes to money and how people exercise that power. So people that make these Decisions about where money goes and why it goes there. They definitely needs something. I would like to call it cultural competency. But there is clearly something that is really missing and it's clearly a very strong power imbalance for people to be able to dismiss experience.
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A
I mean, that is.
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B
And discount it.
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A
Yeah, that's similar to what, you know, I've experienced as a person of color and I've seen others experience as well where your qualifications don't seem to matter as much as a white person's qualifications or you have to outperform by quite a lot to even be considered for position or something. So you have to try very, very hard. And often even then, you know, in, in sort of, you know, some older entrenched institutions are just there. There is that sense of minimization of a person's voice and their skills and. But that shows also it's a repetitive thing and it's, you know, constantly sort of self perpetuating. And that shows that it is deliberate because, you know, there is a choice to not listen and there is a choice to not or funding. And so these are conscious decisions. And so, you know, some of the things we sometimes hear are things like, well, you know, you know, maybe it's just conscious or maybe it's this thing and so, and, and just sort of take out the thorns from the process and just sort of go, you know. Well, you know, this is one of the reasons why maybe, you know, we just need sort of like a two hour thing just to fix this. Because surely if people understand then things will be better. But from what you're saying, it seems as though it's, it's so entrenched that, you know, people are consciously making decisions and you know, and how, how can that be confronted in a way that doesn't endanger those who are already being marginalized?
- [36:01]
B
Exactly, exactly. And I think what the work that I've been doing points to is, is really the need for that systems thinking approach, isn't it? And moving away from siloed approaches to trying to address what some might, you know, call wicked problems, particularly within health. Yeah. Because in any situation that we have there, you know, where, like you're saying there is a. There are either views or ideologies or ways of being that are really quite entrenched. You know, the question that I keep asking is what is it within those other institutions or organizations that is sustaining that, that type of power imbalance to the extent that even if it is not a first nations person who is at the table, but an ally even the ally is dismissed. So what is it really? What's going on on and how many components of factors are contributing towards people being able to arrive at a decision to not fund something not based on experience but based on other factors? Clearly, why is that the case? And so really, I think deconstructing those systems and that piece of work on looking at funding decisions really tried to do that, to say, well, look, this process is not as transparent as it is it should should be. Is there something that can be done to where we can better understand underlying factors for why decisions are made in a certain direction? And there's again, there's probably quite a lot of politics around that as well. That to me is really interesting and it's quite fascinating that there are all these elements, all these factors that are contributing and at the end of the day you end up with a decision that makes it so that, you know, a very critical service or something that the community themselves, you know, Aboriginal and Torres Strait Islander communities have, have said they needed is not funded.
- [38:09]
A
Xingyi, it's been such a pleasure talking to you today. You've brought your incredibly valuable experiences and you're doing such important work and I'm very grateful that we could share that with our listeners today.
- [38:20]
B
Thank you. Thank you so much for having me.
- [38:22]
A
Thank you.
- [38:25]
C
If you're interested in reading the works of today's guest, you can find links to their research in our show Notes. This podcast was produced by Project officer Adobe Plange academic facilitator Amy McHugh and senior external producer Sarah Mashman. Thank you to designer Zayn Arif, who created our podcast artwork SA.