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Racism remains a major barrier to Indigenous nursing and midwifery workforce

Photo: Janine Mohamed, the CEO of CATSINaM
In this episode of the HealthTimes podcast: Janine Mohamed, the CEO of CATSINaM, chats about her career, cultural safety, Birthing on Country, and the impact of racism.

Karen: Welcome to Episode 5 of The Health Times Podcast.  I’m your host, Karen Keast.  Today, we’re speaking with Janine Mohamed, the CEO of the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, known as CATSINaM.  Janine is a proud Narrunga Kaurna woman from Point Pearce in South Australia.  Janine, what prompted you to pursue a career in nursing?

Janine: I think, Karen, for me, nursing just kept coming up from quite a young age.  Yesterday I had the privilege of giving an address at the National Press Club and one of the first memories I have of thinking about nursing as a career was my next-door neighbour, who was the local director of nursing.  He was a man.  He wasn’t an Aboriginal man and he had a fair bit to do with our family. He was an amazing man, actually.  He brought a lot of health literacy into our home and certainly was a trusted friend. 
He just planted that seed in my head and said, “Why don’t you think about nursing, Janine?  You are really interested in health and you’re kind,” and he actually told me I was smart and probably one of the first memories of a non-indigenous person telling me that I was smart, so I think that planted the seed in me that grew and really it just kept being reinforced over the years.  I really loved learning about the body and I really loved helping people, everyone.  Nursing ended up being quite a natural profession to fall into. 

With, I think, a lot of Aboriginal Torres Strait Islander people, sometimes it’s about where our family tells us that we … they see us going … best suited, as well as the profession kind of choosing you.  Yeah, that was my early years in thinking about nursing but I suppose one of the barriers that happened for me was I was living in a small country town and thinking that I would go to the local hospital to do my training.  Then I realised that they’re not going to do training anymore, so I had to go off to university. 

That was, I suppose, the mountain that was before me, when I thought maybe I wouldn’t become a nurse because no one in my family had actually ever gone off to university.  I did that. I stepped out and ended up going to university and then had a long career in nursing, obviously.

Karen: Can you tell us about your career?  Where have you worked?  

Janine: I suppose the other thing that I should say is nursing for me was natural too because I’d seen lots of illness in my home.  As a consequence, to that, I really felt that I wanted to have an impact on Aboriginal health as well, so nursing again was natural to step into, which then led me, once I’d finished my nursing, to work at the Women’s and Children’s Hospital in Adelaide. It was probably the first time at the Women’s and Children’s that I was exposed to the term birthing on country. 

Obviously Aboriginal and Torres Strait Islander women have been birthing for thousands of years before the first formal nursing or midwifery school was set up but this notion or this idea of birthing on country and Aboriginal women’s rights around that came up while I was working at the Women’s and Children’s Hospital.  That led me to work in research and ultimately, I did some work with Flinders University doing a bit of lecturing and research there, whilst still maintaining my clinical role within a number of hospitals in Adelaide.  

From there, I had a number of experiences within the hospital setting that led me to believe that I wasn’t making enough of a difference in Aboriginal Torres Strait Islander health, particularly being just a sole practitioner on the ward.  Research made me start thinking about policy and I was approached by a friend who worked in Aboriginal community control to perhaps think about taking up a job within the Aboriginal community control health sector. 

From Flinders University, I then went and worked at the Aboriginal Health Council of South Australia, so they are the state peak body for Aboriginal health in SA.  I worked there for a number of years, trying to influence state policy on Aboriginal health, so still using my nursing knowledge.  It’s very true when people say to you that nursing can take you anywhere.  You are such a generalist and have such a depth and breadth of knowledge that your formal nursing training gives you that it really can take you anywhere.  It has been the case for me.

I worked with an amazing Aboriginal nurse who became the CEO of Aboriginal Health Council SA.  That was Mary Buckskin.  Mary has left us now but at the time she had profound effect on where my next management role was going to be because at the time I was the Deputy CEO at Aboriginal Health Council after seven years of working there.  She had been working in Canberra and said to me, “Look, Janine, you are really interested in the national agenda.”  She could see that I was very interested from a state perspective as to what was happening nationally.

That prompted me or she encouraged me to then take on a national role.  I ended up working for the National Aboriginal Community Controlled Health Organisation here in Canberra.  Karen, I was only ever meant to be in Canberra for two years.  Eight years later, here I am.   Probably by the time that I was working at NACCHO, I really was working more with the Aboriginal health worker workforce, not so much with the nursing and midwifery workforce.   I had lost my identity as a nurse.  CATSINaM was around as an organisation but I only had a brief encounter with CATSINaM. 

From NACCHO, I became very involved in Aboriginal health worker roles, their education, their career pathways.  Again, that brought me back to workforce and all of a sudden there was this explosion of Aboriginal nurses and midwives in the health workforce.  Just by the very fact that that had happened, I then became re-engaged with nursing and midwifery.  Three years ago, I was asked if I would be interested in working for CATSINaM because they were looking for an Aboriginal nurse and CEO. 

That was living in Canberra.  There were very few of those.  I call myself the accidental CEO because it was an interview that I took and I hadn’t really thought about it until I stepped into the interview and did the interview and walked out and went, actually, I’m really passionate about this and I really think that I could make a difference.  Three years on, I’m still the CEO here.

Karen: CATSINaM is the peak professional body for Aboriginal and Torres Strait Islander nurses and midwives.  What is CATSINaM working to achieve?

Janine: In a nutshell, it aims to achieve more of our Aboriginal Torres Strait Islander nurses in the workforce and that they remain resilient and connected.  Also, that we hope that we can affect the health system itself, in that the health system is culturally safe and respectful.  That’s not only good for our nurses and their recruitment and retention but certainly to improve the health outcomes of Aboriginal Torres Strait Islander peoples.  Then for the non-indigenous nurses, it’s really about ensuring that they receive good grounding in cultural safety and respect and that they realise that it’s a life long journey. 

Karen: Can you tell us about your members?  How many Aboriginal and Torres Strait Islander nurses and midwives are there and what geographic locations are they working in?

Janine: Sure, so for CATSINaM we only … I shouldn’t say only because it’s a great feat.  When I walked into CATSINaM three years ago, we had around 100 members and we are proud to say that we have over 850 members.  Our membership consists of RNs, ENs, nursing and midwifery students, assistants in nursing.  We also have an affiliate membership which is for non-indigenous organisations and indigenous organisations as well as individuals, so non-indigenous individuals.  However, the 850 actually make up our full membership, which I spoke first. 

What we do know is there is around 3036 Aboriginal nurses and midwives across Australia.  They work everywhere, in all of the health sectors, regional or remote and urban locations.  I suppose the other parallel to make is that we only are at one percent of the nursing and midwifery workforce but we’re three percent of the Australian population, so CATSINaM strives to get the parity, to ensure that we have at least three percent of the workforce that’s indigenous nursing and midwifery.

Karen: How important is culture to the way that indigenous nurses and midwives practice?

Janine: It’s central, actually.  It brings the uniqueness of what indigenous nursing and midwifery brings to the profession.  Secondly, for individual nurses and midwives, it’s extremely important for their resilience and their connectedness to remain within the health workforce.  I use the example of myself.  It was probably the strength in my culture that got me through nursing and midwifery, the strength in my identity, because if you are only one indigenous person, say, in a whole hospital, and that’s not uncommon, you are constantly subsumed by dominant culture, so everyone else’s culture, other than your own. 

Often, you can lose your identity, lose your culture, if you are in that environment day after day.  It’s really important for CATSINaM and one of our strategic strategies is to ensure that those indigenous nurses and midwives come together, take pride in their identity and in their culture so that they can continue to perform in their uniqueness that makes them Aboriginal nurses and midwives.

Karen: We may be in the year 2016 but Australia remains home to incredible health inequality for Australia’s First People with life expectancy for Aboriginal and Torres Strait Islander people comparable with people living in some third world countries.  What are some of the biggest health challenges that Aboriginal and Torres Strait Islanders face and are we getting any closer to closing the gap?

Janine: Look, it’s across the social determinants, so I wouldn’t want to say that there’s any one health statistic that impacts more than another.  I think that’s probably … wouldn’t do Aboriginal Torres Strait Islander health justice to just hone in on one.  I will say that some of the sad statistics that we see at the moment, Karen, is Aboriginal youth suicide and we’ve seen that more recently in the current affairs where in the Kimberley we have indigenous youth taking their lives at alarming rates, in fact, four times the rate of non-indigenous Australians, and on a world scale, we have some of the highest statistics in this area. 

For us at CATSINaM when we talk about growing our workforce, when we talk about getting our youth empowered and into nursing and midwifery roles, this does really affect us.  I suppose what are some of the barriers?  For us, our members tell us that one of the biggest barriers is racism within Australia.  As the CEO of CATSINaM, closing the gap is extremely important.  When we talk about solutions, obviously, one of the solutions for us is providing jobs and opportunities.  Growing the indigenous nursing and midwifery workforce not only provides jobs but it increases health literacy in families and in the whole community. 

Because we are the largest Aboriginal Torres Strait Islander health workforce, we believe that we can have a profound effect on closing that gap, as well as affecting the largest non-indigenous health workforce, which is nursing and midwifery.  If we can, I suppose, affect that in a positive way, we can affect closing the gap.  Closing the gap is complex, as I said at the start.  It requires long-term commitment and partnership and investment into programs that work. 

Karen: You are passionate about attracting young people into nursing and midwifery careers. What obstacles do they face and how can we recruit and retain more Aboriginal and Torres Strait Islander nurses and midwives?

Janine: Probably some of the issues with attracting young Aboriginal people to the job is really their own self-beliefs.  When we talk to young people, they believe they can be an AFL footballer.  They believe that they can be an athlete but they don’t think that they can be smart enough to be an Aboriginal Torres Strait Islander nurse and midwife.  For us, it’s about having a national workforce strategy that targets these areas in a strategic way with indicators so that we can be strategic and get our role models into schools to talk to young Aboriginal kids because they will only be what they can see. 

If they have never seen an Aboriginal or Torres Strait Islander nurse or midwife, that’s a really big call to ask them to think about that as a career, clear pathways and support at universities.  The other day I was sitting on a panel for the National Registration and Accreditation Scheme.  One of the non-Aboriginal panellists said to me, “It’s about making Aboriginal health culture and history in our universities relevant to non-indigenous people.  It’s just not relevant for us.  We might never see an Aboriginal client or patient.”  My challenge to that person was, “Okay, what does an Aboriginal or Torres Strait Islander person look like?  How can you honestly say that you never see one if you don’t know what an Aboriginal person looks like in contemporary times and without bias?” 

Really, having Aboriginal health culture and history in our university curriculum is really important for indigenous peoples to see themselves as a part of the knowledges within the professions.  I think the universities ensuring that they have culturally safe environments in the university setting and Aboriginal education support because for some of these young Aboriginal people, like myself, they will be the first person from their family to enter into the university pathway.  People get homesick.  People don’t necessarily have the financial backing, so it’s about ensuring that there’s support for them such as scholarships and bursaries to support Aboriginal Torres Strait Islander students at uni. 

We know that for non-indigenous graduates, 60 percent of the cohort that enrol will graduate.  For non-indigenous cohort, only 30 percent will graduate.  There’s some really clear strategies that are outlined that can support these young people to be retained in the university system and graduate. 

Karen: CATSINaM provides cultural safety training to help professionals and organisations.  What is cultural safety and what needs to be achieved to create a culturally safe health system?

Janine: Probably the way that I would describe cultural safety is knowing thyself.  CATSINaM, yes, we deliver cultural safety training.  Probably one of the biggest misnomers that we have when people enrol is that they believe that they are going to learn about Aboriginal and Torres Strait Islander peoples.  If you have ever seen the Chippendale map of Australia, which has all the different coloured bits and pieces on a map, it shows that there are over 500 different Aboriginal Torres Strait Islander language groups across Australia. 

To think that we could ever really know all the nuances of different Aboriginal cultures sets us up for failure because as indigenous people we are not homogenous.  We don’t share one identity.  Well, we do share one identity but not the nuances that underline that.  Some of the things that people would tell me, which I find quite humorous, “Oh, you shouldn’t look Aboriginal people in the eye.”  Well, that’s not true for all Aboriginal language groups.  What cultural safety is, is about knowing thyself, so it’s for individuals that come into training to unpack their conscious and unconscious biases, attitudes that they bring, and really tie that back to historical events. 

How we formulated some of our biases in our heads, for example, what an Aboriginal person looks like.  It’s challenging our racial radar that we have.  We all have them.  One of the best analogies that I give to what cultural safety training is, is that when we talk to health professionals, we ask them, “Do you ask the question, are you Aboriginal Torres Strait Islander, or not?”  What people report to us is two things.  We don’t ask if someone doesn’t look Aboriginal.  Then we unpack that.  What does Aboriginal look like?  Where has this attitude or this bias been fed from?  They also report that they don’t ask because they might offend someone. 

We challenge that with don’t we ask so many questions that are personal to people?  Why do we think this one question would offend people?  We unpack that and hopefully what we have at the end of our two-day program … and that’s just an example of what we have over an extensive two-day program, is an attitudinal shift for the individual.  That’s the first step that people have an attitudinal shift in creating a cultural safe environment.  Also, I’ll add to that that by understanding yourself better and what you bring to your … the care that you bring to a client isn’t just good for Aboriginal and Torres Strait Islander people. 

It’s good for everyone that you care for.  We also ask participants, “Okay, so now you have had this attitudinal shift, you understand what cultural safety is, you actually have a responsibility to help create culturally safe environments.”  That’s how we start with individuals and with people taking leadership within organisations.  Having other people undertake cultural safety training is certainly how we believe we can make a difference.  CATSINaM has called for a change in legislation.  As well, the Health Professional Act, which we’re all regulated under, in New Zealand we actually find that cultural safety is embedded in their legislation. 

In Australia, we don’t have that.  We believe we’d go a long way to embedding cultural safety within the system if we had cultural safety within our legislation, which then would charge our authorities to ensure that health professionals not only learn what cultural safety is but they demonstrate it in their practices.  Other opportunities that exist is within health service accreditation standards, being able to embed this in health service accreditation standards would then mean that people need to demonstrate it. 

Obviously, CATSINaM does some work with AMNAC to ensure that the nursing and midwifery health professional standards, codes of conduct and university accreditation has cultural safety embedded in them as well. That’s a very long answer, isn’t it, Karen?

Karen: Yes, but a good one.  Thank you for explaining.  It’s not an easy conversation to have but I’d like to ask you about racism.  How prevalent is racism in Australia today?

Janine: Well, I think we only have to go on social media on 26 January to see how Australia participates in racism.  Anyone that doesn’t believe that racism doesn’t exist, I encourage you to have a look at social media on this day. Our membership reports it to us that that’s one of the biggest barriers to the treatment and retention of them.  We hear some amazing stories about what our membership has to hear within our health system.  I know that the National Aboriginal Torres Strait Islander Health Plan, which is a Commonwealth of Australia document regarding their road map, if you like, to improving Aboriginal and Torres Strait Islander health, it names racism in it. 

There must be enough evidence for the Commonwealth of Australia to acknowledge that we need to eradicate racism within our health system.  Racism can be seen in what we don’t see as well, so I give the example of a local hospital.  We don’t see Aboriginal Torres Strait Islander people in the government structures.  Yet often they are making decisions about the health and care of Aboriginal Torres Strait Islander people.  We don’t see Aboriginal people within management positions.  I often to use the AFL as an example. We see an over-representation of Aboriginal Torres Strait Islander people playing football but do we see them as coaches?  Do we see them on AFL or some of the football league sports? 

Racism is about what we don’t see and what we’re shut out from as well.  We have good evidence that … clinical level there’s some fantastic work that’s done by Dr Alex Brown at SAHMRI in Adelaide around cardiac care and Aboriginal Torres Strait Islander people receiving downgraded care pathways when they experience the same symptoms as a non-indigenous person.  They get a different care pathway.  It’s evidence-based within our Aboriginal community child health sector, where we see that they experience the highest or the greatest episodes of care and they have geographically people passing two or three hospitals or health care clinics to actually be cared for at an Aboriginal medical service. 

That’s why it’s so important that we have health professionals trained in cultural safety training.  It’s probably the biggest strategy or the greatest program that we can instil into our health system to eradicate racism.  We certainly see racism as an impact on health indicators that Aboriginal Torres Strait Islander people experience.

Karen: Just further to that, do you have any examples as to how racism can play out within health service delivery for indigenous patients?

Janine: Yes, sure, so like I said, with Dr Alex Brown’s research and experience in South Australia where he looked at cardiac care pathways and indigenous people having downgraded care pathways.  Our midwives have expressed to us about some of the comments made by other midwives about how Aboriginal women should have their tubes tied if they can’t look after their children.  There are comments that are made over … an Aboriginal patient will be in a bed and there will be assumptions made that that person can’t speak English.  The patient will be spoken about, not included in the conversation. 

That’s some of the very basic training that we have in nursing and midwifery about communication, about including the patient in the conversation when you are at their bedside, not speaking about them as if they weren’t there.  My own personal experience, Karen, is one with a major hospital when my daughter, who is very fair skinned, not your stereotypical looking Aboriginal person, being asked, “You’re not Aboriginal or Torres Strait Islander, are you?”  Fantastic that she was asked the question but it was in the tone that she was asked.  An assumption was made about her indigeneity and she was racially profiled. 

The tone in which it was asked implied to her that if she was to say she was Aboriginal Torres Strait Islander, that she might experience less of a quality experience.  Yeah, I mean, I had my own experience and I shared this with the Australian College of Mental Health Nurses more recently, about my own mother when she was in hospital in South Australia.  I walked into the hospital to find that she was nil by mouth, that there was no active treatment happening, that she had thrush all through her mouth but was still receiving oral antibiotics. I quickly assessed that she was on a palliative care regime.  However, she hadn’t been told. 

None of my family had been told and when I had asked the caring doctor why this was the case, he said, “Look, she’s an Aboriginal woman with a mental illness who is not compliant.  I didn’t think that was a priority.”  Yeah, and people are quite shocked to hear that.  We see that people are quite shocked with what happened in Don Dale but unfortunately for Aboriginal Torres Strait Islander peoples, this is our experience and it doesn’t shock us and I think that that speaks to the impact or the lived experience of Aboriginal Torres Strait Islander people that these sorts of experiences aren’t shocking because they happen often. 

Karen: Okay, what about when it comes to Aboriginal and Torres Strait Islander health professionals?  Is there a glass ceiling for indigenous nurses and midwives? 

Janine: Well, what we find, and this is just the evidence, is that Aboriginal Torres Strait Islander nurses and midwives don’t feature in the higher paid sections of the profession.  They are more in the lower rungs of the profession.  At the moment, yes, there seems to be that and we hope that will change.

Karen: What are some of the most common misconceptions non-indigenous health professionals have about Aboriginal and Torres Strait Islander patients?  Do you have any advice as to how they can improve the way that they provide care and treatment?

Janine: I think that some of the misconceptions probably are around health literacy, being able to … I can walk into a room and be racially profiled that I don’t know enough.  I think always checking in with your client, not listening to your racial aura radar and having that respect, I think, is extremely important.  I have already mentioned before, what does an Aboriginal and Torres Strait Islander person look like?  Why should… the misconception around asking the question. Really, challenging yourself around that question I think is a great start to improving your rapport and your relationship and your trust with Aboriginal Torres Strait Islander people. 

Yeah, individually what we can do is to go and to do cultural safety training so you can begin to unpack your own unconscious biases, your own learnt prejudices and I think that puts you on an extremely good pathway to being … adding to what we already know as nurses and midwives, our reflective practice.  Other misconceptions probably are exactly what I’ve mentioned before, which is indigenous people are homogenous.  Indigenous people have lost their culture.  Those are some of the challenges that might impede care.

Karen: I’d like to also chat to you about birthing on country.  Can you explain what it is and why it’s so important to Australia’s First Peoples?

Janine: I think it’s important because we have been doing it for thousands of years.  It’s important because you can name any child and maternal health statistic and we will feature on the bottom of that statistic.  What we experience is at least two times the rate of infant mortality.  We experience low birth weight and that has such a profound impact on trajectories in health for Aboriginal mums and bubs.  What is birthing on country?  Well, it’s different for different nations.  Again, it’s not homogenous across indigenous Australia.  It’s not a cookie-cutter approach. 

Examples of what it might look like, there’s plenty of examples out there that actually work within Aboriginal medical services and good hospitals that are working with Aboriginal Torres Strait Islander communities.  Essentially, what it is, is that indigenous women don’t want to leave their families.  They want to be able to birth on country and they want to receive options and care that is culturally safe and respectful.  Yesterday, what I talked about at The Press Club was that 50 percent of our indigenous mums live in country areas.  Fifty percent of indigenous birthing mums live in country areas.    

That’s compared to 10 percent of non-indigenous birthing mums living in country areas.  What we see in those country areas is a 40-percent decline of closures of maternity services.  What we have is maternity services policy being made for the majority, not the most vulnerable and for our First Nations peoples.  Those are some of the things that CATSINaM is doing at a national level, is trying to get the Australian Government to look at policy that is for the most vulnerable and for First Nations people, if you like, privileging indigenous voices into the national policy space. 

Birthing on country, in a nutshell, I’ve outlined that but what we’re doing with the Australian College of Midwives and [0:33:24.1] is we developed a whole national paper on what birthing on country is and how local hospitals, individuals, can read that paper and begin to make some changes within their local area.

Karen: Finally, what is your overall goal when it comes to Aboriginal and Torres Strait Islander health?  What would you like to see achieved?

Janine: I think what we’d like to see achieved is indigenous people with health outcomes that are if not as good as non-indigenous Australians but better, indigenous Australians that are strong in culture and in identity and in fact a whole Australia with a shared history and with a pride in their First Nations people.  

Karen:  Janine Mohamed, thanks for your time.  Thanks for listening to the fifth episode of the Health Times podcast.  You can subscribe to the Health Times podcast on iTunes.  Don’t forget to check out the range of jobs, articles and other resources on the Health Times website, by visiting www.healthtimes.com.au.

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