Negotiation of culturally safe practice for individuals, organisations and the health system

Ms Robyn Williams1

1CDU, Darwin, Australia


This presentation shares the author’s insights and questions about the position of national rural and remote health organisations regarding cultural safety.

Over the last few years there have been a number of events that have engendered considerable and robust discussion about this topic. Three of the recent occurrences that prompted this paper are: 1. The AHPRA public consultations on a proposed definition of cultural safety; 2. The NRHA cultural safety project; and 3. The CRANAplus Introduction to Culturally Safe and Inclusive Practice Module.

There is still considerable debate about the definition and applications of cultural safety resulting in ongoing conceptual confusion and lack of clarity of purpose and responsibility.

Cultural safety is a “philosophy, an epistemology, and a practice” (Cox & Best, 2019), and is about the cultures of practitioners, professions, and systems. Therefore, it is a model that can and should be applied across the spectrum of health service users and not simply focused on one particular ethnicity or category.

The author wholeheartedly and actively supports Indigenous organisations’ right to develop a specific cultural safety model in keeping with determining their own approaches and outcomes. This right is not being contested here.

However, in the current debate about cultural safety, there is often conflation with Indigenous health issues and priorities; hence a lack of recognition or acknowledgement of the normalcy of culture for all, or of the equal importance of acknowledging social construction of gender, class, race, age and sexual orientation.

It is not the author’s intention to critique the three events mentioned earlier, instead these will be discussed in relation to various national health organisations’ potential role and responsibilities to bring about culturally safe practice that meets everyone’s needs.


Robyn has nursing and education qualifications and nearly forty years of experience of working with Indigenous peoples, primarily in the NT but also all over Australia.

This year Robyn is on leave from Charles Darwin University where she teaches Indigenous health, cultural safety, and rural and remote health. She is also working with various Indigenous health and rural and remote health organisations and projects and is co-editing a textbook on cultural safety and diversity in health care.

Robyn recently submitted her PhD thesis on exploring preparation for health professionals to be effective practitioners in Indigenous primary health care settings.

NSW Rural and Remote health workers and the burden of care in the drought: who cares for the carers? A report on the CRANAplus Bush Support Service 2019 Drought Support Roadshow across the state.

Dr Annmaree Wilson1,Dr Yoni Luxford1

1CRANAplus Bush Support Service, Cairns, Australia


The entire state of NSW is in drought. The human impacts of this environmental disaster in rural and remote communities are only beginning to be understood. It is no surprise that health workers are overloaded with demand for services in affected communities. Not surprisingly they also deal with their personal responses to the situation. Little is known about who cares for the carers during drought?

CRANAplus Bush Support Services has a unique depth of expertise in providing psychological support to rural and remote health workers. A BSS team of clinical psychologists and Aboriginal health workers delivered a Roadshow of mental health interventions and workshops across rural and remote NSW. Using a best practice/mindful/strengths-based approach to raise professional and personal awareness, the project aimed to increase resilience-building skills, capacity to manage stress and the burden of care associated with working in drought-affected communities.

Preliminary findings show that responding to drought is a workforce development issue. Health workers responded positively to the Roadshow. Findings include: participant’s significant appreciation of the team’s deep understanding of issues faced by rural and remote health workers; strategies provided were immediately useful to participants; and unlike other visiting drought support programs, BSS offered immediate and ongoing phone follow up.  Further, the team was confronted by tensions between resilience of health workers (mostly women) and the extent of the burden of care they carried for the drought. The team was exposed to racism while delivering the project, mostly in the form of unconscious bias. Predominantly there was a lack of awareness of how the drought was affecting Aboriginal people, including AHWs; statements that they might be affected at all, were shocking.

At the conference we will discuss our findings in relation to key health and social policy and with evidence from the literature make recommendations for further development.


Dr Annmaree Wilson is the Senior Clinical Psychologist for CRANAplus Bush Support Services.  She completed her undergraduate and post graduate degrees at the University of New South Wales.  She completed her PhD from the University of New England in 2002.  Her thesis topic looked at people’s experience of change in their lives.

Annmaree has worked extensively as a Clinical Psychologist in rural and remote areas of New South Wales, particularly in the area of child, adolescent and family. She has a special interest in the experience of trauma.  As well, she has a focus on Positive Psychology and the use of creativity, such as art, singing and music, as a means of building psychological resilience.  Annmaree developed the workshop portfolio offered by CRANAplus Bush Support Services to develop the capacity of the remote area health workforce.

NT Health – keeping remote nurses safe through policy and practice change

Ms Rhonda Powell1, Mr David Reeve2

1NT Health, Darwin, Australia

2Central Australia Primary Health Care


The Northern Territory (NT) Department of Health has been unrelenting in its implementation of recommendations made following an independent review of remote area safety for nurses and midwives.  This presentation will detail the strategies implemented to date, challenges along the way and future plans. Featured in the presentation will be the on-line professional development modules that have been developed in partnership with Centre for Remote Health and NT Health, and funded by Primary Health Network NT.

In 2017 NT Health endorsed 14 recommendations that aimed to improve the safety, effectiveness and quality of care for nurses, midwives and other staff working in remote areas of the NT. This was supported by a robust governance framework to ensure timelines and deliverables are achieved.

To date the project has delivered; policy reform; 90% completion of repairs and maintenance works; GPS tracking and roll over devices fitted into 189 remote government vehicles and ambulances; internet installation to 318 dwellings; and the development and implementation of 9 bespoke on-line professional development modules. The on-line modules aim to improve the assessment, management, safety effectiveness and quality of care for after-hours clients in remote communities.

Implementation work has now been going for 18 months and continues to be a priority for NT Health. Maintaining momentum and engagement across multiple agencies with competing priorities can be both a barrier and opportunity. Delivering outcomes within expected timeframes can often be in contradiction, as new and unexpected complexities are revealed – to what was thought to be simple and straightforward.

NT Health is committed to the implementation of the 14 recommendations and the journey has led to learnings and further opportunities that we hope to embrace. Providing a safe work environment enhances our ability to recruit and retain highly skilled, experienced and qualified staff.


Ms Rhonda Powell; RN  BSC RPN, MRN

Director of Nursing/Deputy General Manager Primary Health Care – Top End Health Service, Northern Territory

Perceived Preparedness of Recent Dental Graduates in Recognising, Responding and Referring Patients who have Experienced Domestic Violence

Miss Nausheen Mohamed Muhajir1

1James Cook University, Smithfield , Australia



  1. Investigate whether the alumni feel more prepared following the DDV-RRR educational program
  2. Evaluating the difference in self-perceived preparedness between 2016 and 2017 dental graduates
  3. Ascertain participants’ knowledge, perceived gaps in education and understanding of application in practice

Design: Within a participatory action framework, a reliable and validated online survey with 17 core questions was distributed by email to evaluate the difference in self-perceived preparedness between 2016 and 2017 BDS graduates. The hypothesis was 2017 graduates would have a higher perception of preparedness than their 2016 counterparts, having participated in a more current version of the program.

Results: Independent sample T-tests were conducted via SPSS to analyse responses. The 2017 cohort demonstrated an increased perceived preparedness in recognizing, responding and referring patients who experienced domestic violence, thereby proving our hypothesis correct. The majority of respondents identified that the program has made a positive and significant impact on their graduate practice. Feedback from the graduates on the program were largely positive and constructive. The results confirmed our hypothesis since 2017 graduates felt more prepared than their 2016 counterparts.

Conclusions: The program has made a positive and significant impact on graduates. Ongoing evaluation and co-designing will ensure that it continually meets the needs of the students.

Implications for public health: Findings of this study can inform domestic violence continuing professional development (CPD) programs to prepare dentists who can manage patients who are experiencing DV.


This project was conducted by fourth year dental students Nausheen Mohamed Muhajir, Aviral Aggarwal, Gurleen Boparai, Manesha Mahendran and John Dawoud under the supervision of Dr Croker and Dr Carrington at James Cook University. This project was presented at “Are You Remotely Interested Conference” in 2018.

This project evaluated the Dentistry Domestic Violence Recognise, Respond and Refer programme (DDV-RRR) program that is run at James Cook University for Year 3 to 5 dental students to equip students to manage situations where they see patients who have experienced domestic violence. The participants of the study are 2016 and 2017 BDS graduates who have undergone DDV-RRR training.

RIPEN Transitional Planning: Working together to ensure rural and isolated communities have access to, and quality use of, medicines

Michelle Gunn, Denise Breadsell, Michelle Garner


Registered nurses (RNs) holding the Nursing and Midwifery Board of Australia (NMBA) Endorsement for scheduled medicines for nurses (rural and isolated practice) (RIPEN) provide rural and isolated communities access to medicines when traditional prescribers are not available. The importance of this model of care cannot be overstated, as these nurses provide essential services, without which vulnerable people may go without care.

It was therefore a surprise to many that after an extensive national consultation by the NMBA in 2013 it was agreed that the endorsement would be discontinued.  This was because it was recognised that all RNs are adequately prepared in their undergraduate education to ‘supply and administer’ under protocol, and that most jurisdictions have arrangements to support this. However, the Medicines and Poisons legislative frameworks in Queensland and Victoria rely on the endorsement, and legislative amendments will be necessary to ensure that rural and isolated communities have ongoing access to, and quality use of, medications.

Queensland and Victorian Departments of Health have been working with the NMBA on strategic policy and transition away from RIPEN, with the NMBA agreeing to not remove the endorsement until alternative jurisdictional arrangements are in place. In Queensland the Office of the Chief Nursing and Midwifery Officer (OCNMO), the Queensland Nurses and Midwives’ Union (QNMU), and the rural Executive Directors of Nursing and Midwifery Services have worked in partnership to support consultation and collection of expertise to support the amendment of the legislative framework.  Each committed to ensuring rural and isolated practice nurses continue to supply and administer medications to the extent that they currently do.

This presentation will provide an overview of Queensland’s approach to RIPEN transitional planning, including discussion of the consultation process, key issues, policy options and what this means for the broader nursing workforce.  This presentation will highlight the importance of consultation, communication and collaboration when working to develop policy positions that are cogent, inclusive and patient focused.


Michelle Gunn RN, MACN, BN (Distinction), LLB (1 Hons), Grad Dip (Legal Pract), Solicitor of the QSC, Adjunct Lecturer UQ.

Michelle has been a registered nurse for over twenty years and holds academic qualifications in nursing and law.  She currently is employed as a Director of Nursing in the Queensland Office of the Chief Nursing and Midwifery Officer where she has responsibility for Professional Capability statewide. Over recent years she has lead unprecedented policy investments in nursing workforce development. She is a Member of the Queensland Nursing and Midwifery Executive Council, an Adjunct Lecturer at the University of Queensland and a Nursing Expert Panel Member for the Queensland Civil and Administrative Tribunal. Michelle was a scholar of the International Council of Nurses, Global Nursing Policy Leadership Institute (GNPLI) in 2017, and has presented at the World Health Assembly for the past three years.

Denise Breadsell RN., RM., B Hlth Sc Nrs., Grad. Cert. IControl., MPH.

Denise qualified as a Registered Nurse in Queensland in 1982 and a Registered Midwife in Queensland in 1985. Since this time Denise has gained a breadth of experience in nursing and midwifery across rural, remote and urban areas. Denise has worked across public, private and aged care sectors, predominantly in Queensland during the past 40 years. Her areas of practice have included; Public Health Nurse – Communicable Diseases/Immunisation, Sexual and Reproductive Health Nurse, Midwifery, Infection Control, Tuberculosis management, Refugee and Indigenous Health, Quality Management, Nurse Education, Operating Theatre, School Based Youth Health Nurse and Orthopaedics; before starting work with the QNMU 5 years ago as a Professional Officer responsible for codes and standards of practice. She is a passionate advocate of nurses and midwives across Queensland and in her role as Professional Officer at the QNMU has participated in EB9 and EB 10 negotiations and working parties.

Michelle Garner, BN, Grad Dip (Critical Care), RN, M(NP)

Michelle is an experience nurse practitioner and exceptional nurse leader. She is the Executive Director of Nursing and Midwifery for North West Hospital and Health Service and a powerful advocate for rural and isolated health.  She is passionate about removing barriers to nurses and midwives working to their full scope of practice and increasing access to care for rural and isolated communities.  Michelle is committed to the highest standards of care and is currently leading her health service on their journey towards Magnet recognition.  Michelle has a in depth understanding of industrial relations, regulatory and professional issues and is currently a Member of the Queensland Nursing and Midwifery Board of Australia.

Presenters email addresses:

RuralHealthTogether – rural health workforce digital self-care and wellbeing initiative

Laura Hardaker1

Workforce Engagement Manager, Rural Doctors Network (RDN)


In 2018 NSW faced an ongoing, significant drought. Evidence suggested stretched rural healthcare practitioners faced increased mental health patient presentations, an increase in their own mental health stress and a decline in their own sense of wellbeing.

RDN observed the impact on wellbeing of rural health professionals and committed to respond, in partnership, to support wellbeing and self-care to sustain a healthy workforce as they support drought affected communities.

#RuralHealthTogether is a multi-modal digital platform to support rural health professionals through the aggregation of self-care information and tailored support resources. launched in September 2018 via social media campaigns and included messages of support from clinicians, politicians, rural health advocates and administrators.

Responding to evidence, RDN sought to rapidly deploy:

  • support for rural health professional wellbeing and capability.
  • collaboration with content providers.
  • provision of easily accessible resources.

Following feedback from the workforce, organisations, including CRANAplus, are providing workshops promoting positive mental health and resilience to support practitioners; and education focussed on upskilling practitioners to provide enhanced mental health care during crises such as the drought.

In the first six months of operation #RuralHealthTogether results included:

  • 820 practitioners across Australia accessing content
  • Over 50% accessing self-care and news content
  • 70% of access resulting from social media or online referral

Rural health professionals have accessed #RuralHealthTogether for wellbeing and self‐care information and support.

RDN’s program evaluation framework, partnered with digital media experts, will:

  • inform the next iteration of support messages and targeted initiatives
  • further explore social media’s role supporting rural mental health professional wellbeing.

#RuralHealthTogether’s messaging and support are relevant beyond the current crisis and RDN will continue to advocate and facilitate promotion of self-care for the rural health workforce.


Dr Laura Hardaker is a qualified occupational therapist with a PhD in mental health. She worked clinically for over thirteen years and now works for the Rural Doctors Network as their workforce engagement manager. Laura is passionate about the health and wellbeing of all individuals across Australia and her work at RDN has focused on supporting the health workforce by promoting access, quality and sustainable health services. Through the advancement of Rural Health Pro, Laura continues to work on connecting health professionals across Australia.

SCARS – Skin Cancer Assessment Remote Service – Nurse led clinics

Miss Sheena Christensen1

1Silverchain, Walpole, Australia


Skin Cancer deaths in farmers 65yr + are double that of other Australians, with presentation so late that intervention is generally palliative. In 2012, the Australian Institute of Health and Welfare identified that: “a higher priority should be given to maximizing the expertise of health professionals in rural and remote areas including the early detection, early treatment, and management of skin cancer”. In 2014, the National Health Rural Alliance recommended: “people in rural and remote Australia should be recognized as a priority group”.

The Skin Cancer Assessment Remote Service (SCARS) was designed by Sheena Christensen (2017) following professional involvement in 2 devastating skin cancer cases: one a misdiagnosed invasive facial squamous cell carcinoma and another rare BRAF type melanoma and metastasis.

Silver Chain was identified as being able to play a key role in all matters aimed at the detrimental effects of sun exposure. The service, SCARS provide biannually, nurse led, qualified skin cancer screening to remote locations in WA. This includes individual comprehensive risk assessment, full body skin cancer screening with dermatoscopy and one to one education on skin cancer detection, skin self-examination (SSE), sun protection and how to locate skin cancer qualified health professionals. SCARs also provide community education sessions and upskilling of nurses.

The initial pilot service screened 54 patients in 4 days

  • 47% male and 53% female: 20% high risk and 79% medium risk for melanoma and NMSC.
  • 49% had no previous history of skin cancer screening-
  • 6 malignant melanomas have been excised, 8 lesions of varying types SCC and 7 lesions of varying types BCC have been professionally treated and managed.

The provision of nurse led clinics is a professional and effective program to address the early detection, early treatment and management of skin cancer in rural and remote Australia.


Remote Area Nurse Walpole Silverchain Primary Health WA – responsible to provide emergency nursing care, routine clinical assessments, domiciliary nursing care and plan and participate in Health Promotional activities.

Certificate in Primary Care Skin Cancer Medicine. (2016 University Qld and Healthcert)

Professional Certificate Dermoscopy (2017 Healthcert)

Advanced Certificate Dermoscopy (2018 Healthcert)

Professional Diploma Dermoscopy (2019 Healthcert)

Graduate Certificate Medicine – Skin Cancer (current 2019 University Qld)

Should I stay or should I go?: Midwifery workforce in Rural and Remote Australia

Ms Alicia Carey1,2, Dr Alison Teate1, Professor Deborah Davis1

1University of Canberra, Canberra, ACT, Australia

2Charles Sturt University, Wagga Wagga, Australia



There is a significant shortage of both nurses and midwives and particularly in rural and remote Australia (Department of Health, 2013).  Across Australia there are 294,390 practicing Registered Nurses, 26,438 Registered Nurse/Registered Midwife with dual registration and 5,243 Registered Midwives who are currently practicing (Nursing and Midwifery Board of Australia, 2019). Attracting and retaining midwives in rural and remote locations is a constant challenge for health services (Francis, Badger, McLeod, Fitzgerald, Brown & Staines, 2016).

Maintaining healthcare services in rural areas is crucial to enabling women and their families’ access healthcare that is close to their home (Francis, McLeod, McIntyre, Mills, Miles &Bradley, 2012). With staffing shortages there is ongoing pressure with maintaining healthcare and in particular maternity services and with this escalation of ever decreasing numbers of maternity services in rural facilities there is a concern that it is leading to deskilling of practitioners (Francis et al., 2016). Some factors that have been identified to contribute to the issue include: the lack of preparedness for recently graduated nurses and midwives; the lack professional development and the lack of mentoring (Douglas, 2014).

What is happening in your project / what has been your experience?

There is minimal research that looks at Midwifery alone in the rural and remote setting. This research will explore midwives experience working in rural and remote health services and provide recommendations for stakeholders to assist in the recruitment and retention of staff to ensure that women and their families are able to access high quality maternity care.


With rural and remote health services facing additional challenges it is important that there is further research on how midwives can be supported to gaining employment and remaining in the rural and remote workforce to allow woman and families the opportunity to receive high quality, safe care.


Alicia is a PhD candidate at the University of Canberra. Alicia has extensive experience as a registered nurse/midwife and has worked in forensic mental health, rural and remote locations in New South Wales (NSW) and also experience as a remote area nurse/midwife in the Northern Territory (NT).

Alicia has been a Lecturer in Nursing and Midwifery at Charles Sturt University since 2015.

Alicia’s current research includes perinatal mental health tools for isolated women and her PhD focuses on workforce issues for early career Midwives in rural and remote Australia.

Social Networks: Working Together the Other Way Around

Ms Amanda Akers1, Ms Cathy Faulkner1

1Cranplus Bush Support Services


Community-led actions creating social support to enhance social networks, or the other way around? This paper looks at ‘the other way around’. Starting with social connections, a Senior Aboriginal Health Worker, teamed up with a non-indigenous Clinical Psychologist to use their social networks, firstly with each other, and then with the broader communities, to create social support, resulting in community-led actions to enhance them. This qualitative reflection of the delivery of a series of CRANAPlus Bush Support Services workshops is a positive example of Working Together to close the gap in the area of mental health and also for the retention of Aboriginal Health Workers, whose numbers are not meeting the previous ratio to meet the increasing population. Qualities of the social connections are revealed and outcomes of this small team’s workshop delivery, enhancing social networks, resulting in community-led action, are presented, as are suggestions for improving the social and emotional well-being and retention of Aboriginal Health Workers.


Amanda Akers is a Clinical Psychologist who has worked in rural and outreach settings in Northern NSW in both public and private sectors. Amanda’s interest area is drug and alcohol issues, she also works with people suffering from trauma, anxiety, depression and other psychological problems. Amanda runs a private practice in Helensvale, QLD. Amanda also works with CRANAPlus Bush Support Services on a casual basis. She provides after-hours telephone counselling and supervision for remote area health workers. Amanda’s work with Bush Support Services includes running workshops on self-care, reflective practice, bullying, and presenting conference papers on rural and remote issues.


Cathy Faulkner is an Anaiwan woman who has worked for the health service for 21 years. In her current position she works with Aboriginal mothers and babies providing outreach services from Armidale to Walcha, Uralla, and Guyra. Cathy works with 2 midwives and a gynaecologist, assisting clients at high risk, with complex needs. Cathy is a Senior Aboriginal Health Worker who has the respect of her community as a result of her work, as well as running local activities. Cathy is a mother of 6 children and a grandmother of 14 grandchildren. She plays hockey and touch football and enjoys outdoor community involvement.

The availability of chronic disease management and dialysis services, and the patient characteristics of aeromedical retrieval for renal disease within rural and remote, Australia

A/Prof. Fergus Gardiner1

1Royal Flying Doctor Service, Canberra, Australia


Objective: To determine the geographical coverage of chronic disease management and dialysis services available to the rural and remote Australian population; and the characteristics of Royal Flying Doctor Service (RFDS) patients that underwent an aeromedical retrieval for renal disease.

Method: To determine provision of chronic disease management and dialysis services by geographic area, data from RFDS, the Australian Bureau of Statistics, and Health Direct were used. Patient diagnostic data were recorded using ICD-10 coding from 2014 to 2018. Descriptive statistics and Chi-square analysis were used in data analysis, with significance determined at p <0.01.

Main outcome measures: Chronic disease and dialysis service coverage in rural and remote areas, and patient disease type and prevalence (by age, gender, and Indigenous status).

Results: Mapping demonstrated that there are many rural and remote areas that may be without regular chronic disease management or dialysis services. The RFDS conducted 4139 aeromedical retrievals for diseases of the genitourinary system, which represented 3.9% of all aeromedical retrievals. Males were more likely than females (53.9% vs. 46.1%, p<0.01) to be retrieved. Indigenous patients (n=1337, 32.3%), were significantly younger then the wider population (40.2 vs. 58.3, p<0.01). Detailed ICD-10 2-item diagnoses were recorded for the majority (58.2%) of patients. There were significant diagnosis differences (all p<0.01) between genders, including although not limited to, males being more likely (all p<0.01) then females to have acute renal failure, calculus of the kidney and ureter, renal colic, obstructive and reflex uropathy, and kidney failure, conversely females were more likely (all p<0.01) to have chronic kidney disease, disorders of the urinary system, acute nephritic syndrome, tubulo-interstitial nephritis, and cystitis.

Conclusion: The majority of retrievals were from areas without access to regular chronic disease management services or dialysis units, with many rural and remote patients required to travel extensive distances to access services.


Fergus Gardiner has completed a PhD (medicine) specialising in chronic kidney disease management. Fergus has been the lead author on research projects, involving emergency and military medicine, rural and remote healthcare, pathology, and obstetrics and gynecology.  Prior to commencing with the Flying Doctor, Fergus served in the Australian Defense Force before employment in large teaching hospitals and the Department of Health.  Fergus is an academic at the Australian National University were he conducts epidemiology and clinical research. Furthermore, he is a consultant associated with applications to the Federal Government’s Medical Services Advisory Committee, in the field of chronic disease management.