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Which Way?: Educating for nursing Aboriginal and Torres Strait Islander peoples

Bronwyn Fredericks
Research Fellow, Institute of Health and Biomedical Innovation, Queensland University of Technology; Research Manager, Centre for Clinical Research Excellence, Queensland Aboriginal and Islander Health Council (QAIHC), Keppel Sands QLD

Abstract

Cross-Cultural Awareness Training has been seen as a way to improve nurses' knowledge and understanding of Indigenous peoples in Australia (Aboriginal and Torres Strait Islanders) and to therefore improve service delivery and therapeutic care to them. Nurses may have undertaken this type of training in their workplace or as part of nurse education in an undergraduate degree program.

In asking Which Way in regards to this type of training and education, this paper includes the views of a selection of Aboriginal women and highlights the need to extend beyond Cross-Cultural Awareness Training to Anti-Racism Training. Furthermore, that Anti-Racism Training and addressing white race privilege is required in order to address the inequities within the health system, the marginalisation and disempowerment of Indigenous peoples.

Keywords

Australian, Indigenous, Aboriginal, Torres Strait Islander, cross-cultural awareness training, white privilege, anti-racism

Article Text

In parts of Queensland, 'Which Way' is used in a general way in Aboriginal conversation to imply where to now, which way do we go, where are you going or we going, how is that person connected or how does that work? This paper will explore Cross-Cultural Awareness Training, which is primarily designed to enable non-Indigenous peoples to gain an understanding of Indigenous peoples in Australia (Aboriginal and Torres Strait Islanders) and enhance service provision to Indigenous peoples. For nurses this generally means gaining a greater understanding of Indigenous peoples and cultures in order to provide more appropriate nursing care to Indigenous patients or clients. A number of health worksites offer Cross-Cultural Awareness Training to their employees as part of professional development. In addition, universities now include Indigenous content within nursing degree programs for students. A number of Aboriginal women's voices are incorporated within this paper to provide an insight into how Aboriginal women perceive Cross-Cultural Training and what could be done to improve and build on this training.

Cross-Cultural Awareness Training

The past decade has seen substantial growth and emphasis on Cross-Cultural Awareness Training programs. There can be mixed views about Cross-Cultural Awareness Training held by both Indigenous and non-Indigenous people. Puggy Hunter refers to cross cultural training courses as 'hug a blackie' courses (Hunter 2001: 12). Some Indigenous people look on such courses as a positive move towards non-Indigenous peoples coming to understand how to work more effectively with Aboriginal peoples. Like Hunter, others are more cynical of some of the Cross-Cultural Awareness Training programs. Cross-Cultural Awareness Training can be found in a range of government departments, agencies and not-for-profit organisations, and in numerous health settings.

Essentially Cross-Cultural Awareness Training, Cross-Cultural Training or Working with Aboriginal People (all names used for this type of training programs) has been employed as a strategy by workplaces in an attempt to create work environments, which are more appropriate to Indigenous peoples that may be found within those workplaces. This may include the Indigenous clients that those workplaces serve or Indigenous co-workers. Another strategy is employing more Indigenous staff through workforce strategies or recruitment strategies. What additionally needs to be identified are services that offer more appropriate program initiatives to better meet the needs of Indigenous peoples and not just become more sensitive or aware of Indigenous peoples.

Research by Young (1999) is the first in-depth interpretative analysis of Cross-Cultural Training programs and the role they play in Australia. Young explains an expectation underpinning Cross-Cultural Training programs is that if workers know more, they will be more tolerant of people from other cultures and make the appropriate adjustments to their behaviour at work (Young 1999: 205). It is not noted if the expectations of participants or their employers that Young refers to were met.

The issue of diversity has been given considerable coverage in Cross-Cultural Training manuals. For example these have tended to focus on valuing cultures, in particular, valuing the cultural needs of migrants within the host country. Indigenous Australian peoples have not been given the same value-added status as immigrants by the 'host' country. Non-Indigenous workers receive awareness of Indigenous issues in order to primarily service Indigenous peoples as clients and secondly to work with Indigenous people as co-workers. One is valuing; the other is sensitising (Young 1999: 213). Indigenous people are therefore not thought of or valued in the same way. Young asserts that this 'characterises the inadequacy of a 'rights' focus which can position people hierarchically according to societal attitudes' (Young 1999: 213). One needs to ask why Australia's Indigenous people are positioned in this way.

In the past decade there has been a shift from a 'top down' to a more 'bottom up' approach to Cross-Cultural Training with some of the health professions themselves beginning to explore how they can take some responsibility for their own education on issues. There is evidence that some of this Cross-Cultural Training and curriculum development has involved Indigenous peoples. For example the Council of Deans of Australian Medicine Schools (CDAMS) (2004) Indigenous Health Curriculum Framework and the training package explained by McKendrick (1998). In contrast there are others, including some nursing programs, that don't. My argument is that the thread of inclusion needs to be woven through all programs taught within health domains. While it may be possible to have one module that may heighten awareness and develop some knowledge and skills in working with Indigenous peoples, it does not necessarily alter the way an individual perceives the remainder of the curriculum taught. I am advocating that it is not enough to just have one module. There is a need (based on my experiences and discussions with others) for curricula to be widened to move away from viewing health merely within a western framework and worldview. Just as health policies put people into 'body parts' in a process of dissection, cultural training can segment and dissect people. In the dissections what remains a constant is the dominant western worldview and in Australia's situation it is a colonising worldview. I believe that we need to get people thinking out of this narrow worldview and away from the idea that they can do an Indigenous module from anything between four hours to four months and that I've 'done' Indigenous health. My experience has been that if students choose not to relate such learning within their own paradigms on health they will find it hard to incorporate within their existing knowledge base. (I believe this to be true about all curricula regardless of discipline, but here I am limiting my very brief discussion to the nursing domain).

McKendrick (1998: 737) states that if health professionals and students are to,

... learn how to work with Aboriginal people, to treat Aboriginal people; they must be able to listen to what they have to say. If we are serious about improving the teaching of Aboriginal health we must listen to what Aboriginal experts say.

I argue that basic respect needs to be a platform from which the listening can take place. Within many Indigenous communities there are Indigenous people who are recognised by other Indigenous people as the 'speakers' on health matters. This is in the same way, that there are the speakers on law matters, native title and housing and other areas. There are Indigenous people via community nomination, representation and election processes who are also 'speakers' at regional, state, territory and national levels. For example the Queensland Aboriginal and Islander Health Council (QAIHC) represents over 20 Aboriginal and Torres Strait Islander community-controlled health services in the State. QAIHC has the authority and expertise to speak at the State level and represent Queensland at national and international levels. The issue of who speaks, who are considered experts and who has authority via recognition, representation and election is a complex matter.

According to McKendrick (1998) listening is the first step and from the listening comes the dialogue. Once there is dialogue learning can occur around what is important to Indigenous people in terms of health and wellbeing, making it possible, for western trained health professionals to work out the best way to work with Indigenous peoples. This is easier said than done. Indigenous people have been saying for a long time what is health and wellbeing, what could happen, what needs to happen and some of the best ways to make that happen. Despite this many non-Indigenous health professionals, academics, researchers, government officials and policy makers continue to seek answers from within their own worldviews and knowledge bases. There seems to be always some new response, some new words and some new approach to 'fixing' the Indigenous health 'problem'.

In terms of my research, several of the women interviewed acknowledged that staff in a number of services in their community had undertaken Cross-Cultural Awareness Training. The women did not comment on whether they had noticed any changes in the services.

Aboriginal Women's Voices

The following Aboriginal women's voices are drawn from a research project undertaken in a Queensland regional community which attempted to answer the question 'how the relationship between health services and Aboriginal women can be more empowering from the viewpoints of Aboriginal women?' The assumption underpinning this study was that empowering and re-empowering practices for Aboriginal women can lead to improved health outcomes. The focus of the study arose from discussions with Aboriginal women in a specific community as to what they wanted me, another Aboriginal woman, to investigate as part of a formal research project. The terms empowering and re-empowering were raised through these early exploratory discussions. They were later discussed during interviews. Re-empowerment was discussed from the viewpoint that Aboriginal women were once empowered as sovereign women who had control over all aspects of their lives. Aboriginal women became disempowered as a result of colonisation and thus the term re-empowering was discussed.

The ethics process included presentations before an Indigenous inter-agency meeting of over 50 community representatives from community organisations and Indigenous work areas, an Aboriginal women's meeting and an Indigenous organisation that was recognised as having responsibility for women's issues. This was in addition to a university ethics process. A panel of supervisors oversaw the research project, including an Aboriginal woman who was recognised for her long-term involvement in Aboriginal women's activism. She was nominated by other Aboriginal women in the community as the most appropriate person to be a cultural supervisor and to assist in any cultural ethical dilemmas. She worked with the other two supervisors who also provided specific roles.

Twenty Aboriginal women participated in in-depth interviews in a participatory-action research process, which incorporated Indigenist methodologies as described by Rigney (1997; 1999; 2001) and decolonising concepts asserted by Smith (1999). This research process was developed in consultation with Aboriginal women in the community and through discussions with Indigenous researchers in Australia and overseas. Research processes were sought that would not only be academically rigorous but that would not perpetuate further disempowerment and marginalisation for Aboriginal women and the Aboriginal community.

There were mixed responses from the Aboriginal women who were interviewed to the question of Cross-Cultural Awareness Training. Some women were apprehensive about the outcomes while others had thought about Cross-Cultural Awareness Training for some time and had experience in the area. For example, some of the women had co-facilitated training or been guest speakers on Aboriginal culture in organisational settings and university environments. Others in contrast had little knowledge of the training and different health settings. Most of the women demonstrated that they had an understanding of some of the complex issues around Cross-Cultural Awareness Training even if they had little involvement. As a group the women repeated many of the findings from Young (1999). Linda a participant in the study provides an example of the apprehension:

... sometimes I wonder about those programs. I mean it's good that people do training first of all that they have an open mind to want to go and learn something different, but I think a lot of that stuff happens if you are committed and you make a resolution to practice those things everyday of your life and not just go off for a two day course and have a piece of paper to say I know everything there is to know about Murri stuff now ... it's more how you operate on a day to day basis ... what you do know about Aboriginal lifestyles ... comes down to the individual perspective, putting yourself out as an individual ... sometimes people don't want to get that close, it's still keeping Murri people at an arm's length.

The point raised by Linda is that some people seem happy to do the training, provided they do not have to change their practice or adopt the training or reflect on their ideas within their normal modes of operation. This can be seen as non-Indigenous people coming to know Indigenous people provided their personal level of comfort isn't challenged. Moreover, this means they must have a willingness to let go of stereotypes and to accept what Indigenous people's lives actually do encompass. If there is no long-term commitment from individuals to making some real changes then such changes are unlikely to happen. In addition, past participants might be aware but not act on knowledge gained from the training programs.

The majority of Aboriginal women I interviewed had concerns around the length of time the training was offered and made comment about how long it may take to change some people's ideas. For example Julie explained that 'in the long run the person has to change the attitude ... [they] could go to 10 classes and still not change...'. Grace stated it 'should be [a] core component of their training before they get out into the services, [it] should be done continuously, one day or three days, [is] not enough....' and Sarah asserted that 'I don't agree with two days, [it] needs to be done on a reasonable time frame ... it's gotta be treated pretty serious ... putting ideas into action is another thing'.

Julie added a very important point to discussing the time frame and with the training that it 'might be fixing up what's there but it might not be catering to our people ...'. She is expressing a real concern that while action might be taking place in an attempt to 'fix up' what is happening in terms of communication or interaction, that this might not be the only issue or the most important issue. It could be that the service model or the type of service may be inappropriate. Undertaking Cross-Cultural Awareness Training and then trying to apply the training with inappropriate services will still have minimal impact. The problem is if the workers don't additionally look at the service model but instead think 'well I did the training and tried it out and it didn't work' or 'Indigenous people didn't respond. In this, blame may be placed on Indigenous people. For example, that it was Indigenous people that 'rejected their efforts' or that it was 'Indigenous people who didn't want the particular health or human service program'. There were no specific comments made as to whether the women had noticed a change in the service delivery models as a result of people undertaking Cross-Cultural Awareness Training. A question may need to be asked whether a connection is made in the various training programs between the content and health service models by participants or facilitators or lecturers.

The content of Cross-Cultural Awareness Training differs depending on who delivers the training. Sometimes the training can be geared to a specific work place or a particular profession. The Cross-Cultural Awareness Training delivered within one health organisation in the community of study was written specifically for the broader health workforce. Alice stated that she knew that this particular training course had problems with some health personnel not prepared to do the course:

... to be really honest I, if, while it's a good program, I think, I have heard it has its ups and downs ... nursing staff and doctors and that not willing to participate in the program ... generally I think it's a good idea ... In time I reckon' it would you know break down that, that wall there.

Alice identified that she knew that some doctors, nursing staff and others were not willing to do the course. There are many reasons workers may choose to do the training and many reasons why they feel they should not. For example, do they have large numbers of Indigenous patients or clients, is their supervisor willing to find a replacement for them while they are at training, is it seen as necessary in their worksite, are nurses given the opportunity or seen as a priority to receive the training? Are nurses asked to make choices between which training they do in any year, so that Cross-Cultural Training is put up against other training? These reasons and many others impact on how people participate within the training. Mary identified that there was a difference in attitude between those people undertaking the training because they 'want to improve' and those people who do it because 'it was a directive'. Indigenous people have a general awareness that in some workplaces people are directed to do the training. This could be because they work specifically with Indigenous peoples or because there have been some issues identified with that worker's behaviour in relation to Indigenous people. In choosing the words 'In time I reckon' it would you know break down that, that wall there', Alice expresses that she believes that the training has a benefit in addressing the barrier between cultures.

The women I interviewed all suggested ideas on how to improve the curriculum of Cross-Cultural Awareness Training packages. Helen stated that she 'would like to choose and pick the people delivering that service ... may be I'm too critical, when I see people up there saying what they shouldn't be saying'. Helen explained that she would like to be involved in such training, for example helping or assisting for change if she was asked, that it is 'hard to be diplomatic with people who use ignorance as an excuse for not wanting to know'. Here Helen was referring to the participants in training.

Sally discussed that people who undertake training should gain an idea of the lives behind the statistics and not just the statistics. She wanted them to have 'more an idea of what Aboriginal people go through or more appreciation ...'. Sharon and Denise both suggested training that would complement the more formalised workplace training course in a room and education undertaken in a room or lecture setting within a university. Sharon believed that all the new medical interns at the local State Hospital needed to do the Cross-Cultural Awareness Training. In referring to them and other people within the health arena she said, '... those people in other places they need to come and work with us (Aboriginal people) and see how it operates and how to service our people ... they'll get an understanding of our culture and what it's all about it'll make their service a lot better too'. Denise looked to the community-controlled health service as a place where nurses could gain training to work along side Indigenous people and within an Indigenous environment.

Denise additionally thought through some of the processes and suggested that it 'can't be that hard for that mob to go from their work place to some other work place' within the organisation that they worked for. She explained that when she was at the local State Hospital she saw a nurse in the Maternity area and some months later she saw her working in another area of the Hospital. Denise suggested that training and professional development opportunities should go beyond the Hospital site. Opportunities could be created for work place exchanges, placements in other work environments or organisations or situations where workers work along side other workers, including Indigenous workers.

Charlotte considered that Cross-Cultural Awareness Training was a useful option to a workplace that did not have any Aboriginal workers. 'I think it would be really good at least if they can't get Aboriginal workers at least they have some knowledge and understanding of someone with an Aboriginal culture...'. Sometimes however, having an Indigenous worker provides an excuse for non-Indigenous workers not to serve Indigenous clients or not to learn about Indigenous cultures within the service model in which they work.

Can training bring about change?

Cross-cultural Awareness Training may only be awareness raising and showing people how to better communicate with Indigenous peoples. In some cases it may not have any impact on the individual participants at all. In other cases it may be influential in changing long held beliefs and attitudes about Indigenous peoples and assist in better communication with Indigenous peoples. What is on offer to most government employees, is training that is generally aimed at how they can understand Indigenous peoples better and how they can better service Indigenous peoples. Pettman (1992: 36) put the position in discussing Aboriginal Studies that such programs are:

... frequently taught within education, social work or health departments, which tend to encourage (with notable exceptions) a social problem, social welfare, and culturalist approach. A concentration on trying to understand 'them' better so that 'we' can do our job better both underlines their otherness, and detaches their decision making from wider highly political, structures and processes...

In this way, it could be said that the training does focus on 'otherness'. It is difficult to think how training could extend behind this paradigm given current education processes and Australian society. How can the training be used to challenge the societal inequities or structural constraints that maintain Indigenous disadvantage? The training may lead to some awareness of the inequities and constraints. I am unsure whether the training and education gives an understanding to participants and students that Indigenous disadvantage also means that others are advantaged, or whether the participants and students see connections between themselves and Indigenous people and processes that may be required to assist in bringing about change. Young (1999: 212) asserts that:

... CCT (Cross-Cultural Training) is an individual change strategy which relies on learning interpersonal interaction processes which, at the very best, might start a collective conscientisation process leading to change at an organisational level for the betterment of the social position of people of different cultures and backgrounds...

Note that Young uses the words 'at very best' and 'might start'; she does not say 'will start' or that it does or if the programs were at their very worst or average. She additionally states that it is about interpersonal interaction, and not necessarily about attitudes or beliefs unless the individual participants choose to follow this path. In terms of the short cross-cultural training programs Young comes to the conclusion that 'cross-cultural training is never going to produce, of itself, structural change' (1999: 212). What needs to be explored is what type of education or training might support these changes or assist in making change.

Educating for Cross-Cultural Interactions

Public health policy has attempted to direct other forms of training and education in an attempt to include Cross-Cultural Awareness Training in health curriculum. For example the House of Representatives Standing Committee on Family and Community Affairs' report, Health is Life: Report on the Inquiry into Indigenous Health (2000: 107), contains the following recommendation:

Within two years, all undergraduate and post-graduate health science courses should include an effective cross-cultural awareness component, as well as dealing in detail with the current health status of Indigenous Australians and the factors which have contributed to their ongoing social and cultural disadvantage.

All continuing medical education courses should also expand on these matters and continue to expose health professionals to cross-cultural learning. (Recommendation No. 29)

Some six years after the recommendations were made, it needs to be asked, what has changed? Are there now a few hours of Indigenous content designated as core content in an entire nursing undergraduate degree? Is there a semester long module of teaching focused on Indigenous culture and Indigenous health issues? Is this knowledge subjugated from the main curriculum? Is the Indigenous content governed by the content choices of lecturers? How is this monitored? What preparation did the lecturers undertake in order to best make these decisions? Are there any Indigenous people employed as lecturers? Are they employed on a short contract basis or are they in tenured positions? Are, Indigenous 'guest speakers' brought into the nursing school or Faculty to share their knowledge during the 'Indigenous four hours' or segment? Are the Indigenous 'guest speakers' Indigenous people with knowledge and expertise in health? Is there Indigenous imagery within the School or Faculty via paintings, pictures or posters without Indigenous people really being physically present or included throughout the curriculum? Are Indigenous people therefore just part of the 'pretty business' of the interior decor? The present inequity privileges the Western knowledge systems of health and marginalises Indigenous people's health concerns and us as people despite the appalling situation of Indigenous health in Australia.

There may be unresolved questions within Technical and Further Education (TAFE) and universities as to where in the curriculum Indigenous content might be included, when they 'are already stretched'. The questions that still remain include: how important is such training and education and how important is it to address Indigenous health issues in Australia? If Indigenous health issues were of major concern and Indigenous people were considered of worth, training and education would be provided and curricula would be changed to reflect content that is seriously attempting to address Indigenous health issues. Indigenous people would be included in curriculum development and education in ways in which Indigenous people could participate fully and be valued. I have been asked in the past to be involved in curriculum reviews where I couldn't think anything else other than that the Indigenous involvement was like an afterthought. I have been left feeling highly stressed, thinking I have to be involved because if I don't, we'll (Aboriginal people) be left out of the curricula again. If I say I can't because of my workload priorities or because I was invited late in the review process and I don't, the school or faculty might say that they asked an Indigenous person or people, and the Indigenous person or people didn't take up the offer to participate. It will be said as I have heard before, 'Indigenous people didn't participate' rather than 'the terms of the review and the timeframe that the school set made it difficult for Indigenous people to participate'. This is not limited to nursing and professional curricula, it happens in other disciplines too. For example, recently another Aboriginal woman and I were asked to part of a university Aboriginal and Torres Strait Islander curriculum review team. Sometimes nursing students in this particular university select electives from this area and someone from the nursing school was one of the reviewers. The other Aboriginal woman and I were not offered any monies to participate in a two-day workshop and to critically read (at least three days) the learning materials in preparation for the review. We were expected to give our knowledge, skills and abilities for 'our people'. Several non-Indigenous people who were the 'Indigenous experts', that is, who taught the Indigenous content and who were also going to participate in the review were employed within that institution and thus would be paid for their five days of work. The person from the nursing school was still paid her wage while taking part in the review. The result would have been if we agreed to do the work, that we as Aboriginal women would have given our time, skills, abilities and specific knowledge in Indigenous content for free and the non-Indigenous 'Indigenous experts' would have been paid for their time, skills, abilities and specific knowledge in Indigenous content. We did not participate in the review.

Swendson and Windsor (1996: 9) argue that, in nursing, in trying to understand cultures:

... nurse education would be better directed towards the development of critical understanding of the complex political and economic relations that have perpetuated racial divisions and the fundamental structural reforms required to address this situation.

According to Swendson and Windsor (1996: 9), 'cultural sensitivity' means that people generally remain neutral and avoid dealing with political judgments in dealing with human difference. They argue 'cultural awareness does not equate with equality'. Cultural safety is another concept that is being used within health care settings in Australia. It was originally developed by New Zealand Maori nurses attempting to overcome what they saw as the failure by the general health care services to recognise Maori culture and service Maori people (See Ramsden 1990; 1992; 1996; 1997; 2000; 2001). Queensland Health has adopted the principles and practices that underpin cultural safety (2004). I would argue that while cultural awareness, cultural safety and trans-cultural nursing may answer problems and dilemmas at the point of service access and delivery, it often does little in terms of long term change unless health professionals take action within themselves, their work environment, and the system in which they work and within the broader society in which they move. If this does not happen, we, Aboriginal people, can become yet again the 'problem' that needs to be overcome by health professionals through greater education and understanding. Furthermore, it leaves the present health system and health personnel in the position of domination.

Limitations of Cross-Cultural Training

The mere creation of awareness does not bring about the structural changes needed and the recognition of our inherent Indigenous rights, nor the reflection on the positioning of non-Indigenous people by non-Indigenous people. It focuses the lens on Indigenous people, as being under-serviced, needy and problematic to non-Indigenous people to some degree in that their efforts to service us have failed. If more people become more cross-culturally aware, what will it bring for Indigenous peoples aside services and programs that we are entitled to and that fit within Australian society's bureaucratic structures? It does not mean that we as Indigenous peoples will be any healthier as Indigenous people as defined by Indigenous people. It does not mean that we will be exercising our rights, roles and responsibilities as Indigenous peoples or that non-Indigenous people will be exploring how they acquired their privileged positioning within Australia and move to re-dress their positioning. Cross-Cultural Awareness Training needs to be undertaken in more depth and begin to explore what has come to be termed 'white race privilege' and incorporate anti-racism strategies. More focus is needed on the role of non-Indigenous people in their societal positioning and our positioning as Indigenous peoples and structural change.

Anti-Racism Training incorporates more than Cross-Cultural Training. The models of Anti-Racism Training and workshops currently being conducted in the United States, challenge, racism, sexism, class exploitation and oppression, homophobia, environmental degradation, and support multi-faceted struggles for social justice in the United States and internationally (Ashmore 1999; The People's Institute 2002; The Anti-Racism Training Institute of the Southwest 2002). They incorporate and challenge the notions of racism and unearned white race privilege, training identified that is needed within cultural training programs in Australia. Ashmore states that 'Racism is a systematic form of oppression by the dominant culture in power in which people are oppressed economically, socially and politically solely based on skin colour' (1999: 1).

The People's Institute for Survival and Beyond (2002) is a multi-racial and anti-racist network of organisers and educators dedicated to building a movement for justice by ending racism and other forms of institutional oppression. It works from the premise that racism is a barrier to building effective conditions for change. Furthermore, that 'racism has been consciously and systematically erected and can be undone only if people understand what it is, where it comes from, how it functions and why it is perpetuated' (The People's Institute 2002). In Australia, as with the United States, white privilege acts as a major barrier to building the kind of social movements that could bring fundamental change. Social justice activists have a real stake in tearing down this barrier if they wish to bring about change. The People's Institute explains that in the United States, institutions and culture gives preferential treatment to peoples whose ancestors came from Europe over peoples who came from elsewhere and that Euro-Americans are exempt from racial and national oppression inflicted upon peoples from elsewhere (2002). We see parallels in Australia with preferential treatment being given to Anglo-Australians, or people from Europe and the United Kingdom over peoples who are Aboriginal Australians, or those people who originate from Asia, Arabia, Africa and the Pacific Islands.

The work of The People's Institute for Survival and Beyond (2002), Ashmore (1999) and The Anti-Racism Training Institute of the Southwest (2002) has connections with the writings of Moreton-Robinson (1999; 2000) and Tannoch-Bland (1997) centred on white race privilege and racism in Australia. Racism is embedded in Australia's colonial history, within Australia's institutions, policies and culture and within the psyches of Australian people. It commenced, with the arrival of the British, which began the theft of land, murder, massacres, poisoning, torture, dispossession, internment, enslavement and genocide (Evans, Cronin and Saunders 1975; Kidd 1997; Manne 2001; Rintoul 1993 and numerous others). The acts committed against Aboriginal and later Torres Strait Islander peoples were all based on race. Some documents of the early 20^th Century not only revealed overt racism but also the belief that Australian Aboriginal peoples would be either exterminated or assimilated as time went by (Kidd, 1997). Racism continues today often in more subtle and less overt forms. What racism does within the health system is to maintain the continual marginalisation and disempowerment of Indigenous people. Disapproving of racism and simply changing language is not enough to change the situation. Tannoch-Bland (1997: 10) speaking as a non-Indigenous Australian suggests that:

Race privilege works to over empower us - conferring dominance - permission to control on the basis of race. It gives licence to one group of oppressors ...White Race Privilege still gives us a licence - we can be ignorant, oblivious, arrogant, destructive, insensitive, patronising, paternalistic ... Our arrogance is damaging us.

She adds that 'it is through exposing our White Privilege that we can begin to unpack and unlearn racism'.

Anti-Racism Training in which participants develop an understanding of white race privilege needs to be part of all Cross-Cultural Training programs. This will cause some discomfort as racism in Australia has generally focused on those who are oppressed and on race hatred. Racism has primarily been seen as a problem for Indigenous peoples and not for white Australians. Racism needs to be seen as a problem owned by all Australians, if it is going to change current practices. If we really want to dismantle racism then we must be willing to recognise it in all its forms. Thus the conversation needs to additionally include the reality that some Anglo-Australians who are non-ruling class are both oppressed and privileged. They are oppressed based on the basis of their class, gender and sexuality and may be on the basis of religion, culture and ethnicity, age, disability and politics, while being privileged based on the colour of their skin and their cultural connection, and affirmation, with white race privilege. The difficulty is when oppressed Anglo-Australians, Celtic-Australians or European Australians protest against their own oppressions, while remaining silent about racism and white privilege, they become oppressors of Aboriginal people and other groups. The silence of these Australians and other white Australians acts as a form of consent.

Conclusion

This paper has reflected on Aboriginal and Torres Strait Islander Cross-Cultural Awareness Training and education. In the past cross-cultural awareness training and education has primarily been designed to enable non-Indigenous people to gain an understanding of Indigenous peoples and cultures in order to provide services to Indigenous peoples. Nurses may have undertaken the training in the workplace or as part of nurse education in an undergraduate degree program in order to enhance nursing care to Indigenous patients or clients. In asking Which Way in regards to this type of content, training and education, I have attempted to highlight the need to extend beyond Cross-Cultural Awareness Training to Anti-Racism training and addressing white race privilege in order to address the inequities within the health system and the marginalisation and disempowerment of Indigenous people.

I believe one of the answers in addressing Indigenous peoples' health is for health professionals and those working within the health system to:

1. Become aware of Indigenous peoples, histories, cultures and statistics.
2. Move beyond awareness to an anti-racism framework.
3. Develop an understanding of white race privilege; white advantage and Indigenous disadvantage within Australian society.
4. Address your positioning in regards to white race privilege in Australian society and the health system. In not addressing your own positioning you maintain the status quo.
5. Move towards establishing Indigenous friendly environments and partnerships with Indigenous peoples.

These five points are what individual nurses and health professionals can do. For a health service or organisation to change it needs to reflect on the way in which white race privilege and racism permeates its structure, service model and staffing base.

Throughout Australian history, non-Indigenous people have joined in the common cause with Aboriginal people to fight colonialism, racism, imperialism and the on-going impacts of these on Indigenous people's lives. There have been non-Indigenous people who have wanted to be part of the struggle and to make changes. Today, the scope of the battle has widened with more non-Indigenous people joining in the Indigenous struggle and expressing doubt not only about the racist institutions and agencies, but also the racialist narratives of Australian society and the purported superiority of all things British, European, American and 'Australian'. Sometimes however, the support against racism and for equity is flawed, as there may be best intentions that contain the coloniser's and non-Indigenous white privilege of what is right, just, anti-racist, and culturally valuable and viable. It is a non-Indigenous white privilege positioning and not an Indigenous standpoint. In this, individuals need be open to seeing how their own histories and experiences of white race privilege have distorted their best intentions and be prepared to challenge themselves just as they are willing to challenge others. This can cause real frustration and a crisis in terms of what it means to be an 'Australian'. I have witnessed this within some non-Indigenous people as they come to terms with themselves as white Australians who have benefited from privilege while others have been disadvantaged, it can bruise a positive self-image and make someone depressed with the reality of others lives in relation to one's life. This can be a painful surprise. Indigenous people may also be challenged, only from another lens. The real obstacles are recognised, that is the 'Australian' conceptions of who Indigenous peoples and non-Indigenous people are and what we are supposed to be and the picture becomes clearer as to who we really are as human beings. Are you as nurses and the nursing profession willing to try?

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