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.

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.

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).

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 self-
determination 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.

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 categorized 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).

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.

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.

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 ‘two- ways’ (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.