User:Dr Liz Rix/sandbox

Reflexibility is the ability of institutions to reflect on and acknowledge the negative impacts of their institutional behaviours, policies and practices on individuals and/or minority groups and provide flexibility within services to address the diverse social and cultural imperatives of these groups (1).

Origin
This word, now obsolete in its original sense, emerged again in 2014 to describe a key finding from the doctoral studies of an Australian renal nurse specialist who had identified the role of institutional racism in the lack of culturally safe, and accessible services for Australian Aboriginal and Torres Strait Islander peoples when accessing healthcare (1, 2).

Racism is firmly embedded in institutions such as healthcare (3). Significant changes in systems policies and practices are required in order to reduce the impact of institutional racism and enable systemic change (4). There is an urgent need for government and non-government organisations to spend time out from their core business, whether that be in health, education, justice or other services - to examine residual racist practices and attitudes that continue to marginalise and discriminate against vulnerable minority groups. Systemic racism is defined as: “Requirements, conditions, practices, policies or processes that maintain and reproduce avoidable and unfair inequalities across ethnic/racial groups (also known as institutional racism)” (5) “Systemic and/or institutionalised racism influences access to housing, education, employment, income and living conditions, and also to information, resources, influence, representation and medical facilities and services” (6).

Background
Individual healthcare clinicians and researchers are required to practice reflexivity (7), also known as reflective practice (8) to understand any previously unexplored or unconscious attitudes and beliefs that may impact on their practice (9, 10). Healthcare organisations and institutions should also practice a form of critical reflection on their institutional ‘culture’ in order to expose and address racism or discriminatory policies, practices and attitudes embedded in their systems (5). These may be the residue from the recent past when racism was the overt ‘norm’ in white/European government and non-government institutions (5). It is well known that lack of reflexivity and examination of existing social orders and norms can  maintain and reproduce discriminatory practices into structural systems within healthcare (11)  Confronting the impact of institutional racism on Indigenous peoples and other vulnerable or marginalised cultural groups is essential if health inequities are to be addressed (3, 12). Achieving this however, will require a multi-tiered commitment that links policy to practice (5, 12, 13).

Health institutions operate within an abundance of evidence informed/based practice, and policies (14, 15). Health policies acknowledge and support the need for services that include the diverse cultural needs and concerns of patients accessing their services (16). These policies frequently fail to translate into practice in clinical areas where patients must interact with healthcare professionals and systems that have no connection to their cultural background (6).

Critical self-reflection practice
The ability to reflect on one’s practice is now recognised as a vital skill for all healthcare professionals in developing self-awareness and examining emotional responses in the clinical setting (8, 17, 18). Reflexive practice is also an established technique used widely by social scientists (19). Critical self-reflection is a pre-requisite for the delivery of culturally safe and competent treatment and care to healthcare clients from vulnerable or marginalised populations such as Indigenous peoples from nations colonised by Europeans, for example Canada, Australia and New Zealand (20)

Health institutions must develop a similar process: an ‘organisational reflexive practice’.

According to literature on organisational change, those working at the institutional level need to use both personal and group reflexive practice to examine all levels of operation (21). Reflexivity is required not only for individual professional practice, but also within organisations, to examine embedded culture and practices and how these can be shifted. Redesigning hierarchical institutions requires new ways of operating that are more relevant to the social conditions of consumer groups (21, 22).

Institutionalised racism thrives in organisations without reflexive practice
Just as individuals must use reflexive practice when working clinically or researching with people from cultures other than their own, institutions are required to reflect on their policies and behaviours that, through institutional inertia, allow residual racism to persist. Residual racism has evolved from and been shaped by previous administrations’ blatant disrespect of cultural diversity as evidenced by Australia’s colonial history of ignorance and disrespect of Indigenous peoples and their culture. Deep and sustained organisational critical reflection on the past injustices and overtly racist policies inflicted on Indigenous peoples by mainstream institutions appears necessary to allow individual goodwill to surmount this inertia and result in improvement. Achieving this will demand ‘real flexibility’ and responsiveness by institutions as they reflect on the delivery of services and the education of their staff. In an attempt to articulate how health and research institutions must examine current shortfalls in meeting the cultural and health needs of individuals and minority groups, this word had been ‘created’ to capture what this requires of institutions (1).

Indigenous consumers accessing healthcare through mainstream health organisations do this within a context of ‘residual’ institutional racism that remains embedded in the fabric of institutions that assume the superiority of Western assumptions, and reflects a history of overt racism from the recent past. Ameliorating this requires making changes within hospitals and health services that acknowledge and reflect the cultural and family obligations of Indigenous peoples (1, 12).

1.            Rix E. Avoiding the costly crisis: Informing renal services design and delivery for Aboriginal people in rural/regional New South Wales, Australia. Sydney: University of Sydney; 2014.

2.            Rix E, Barclay L, Stirling J, Tong A, Wilson S. The perspectives of Aboriginal patients and their health care providers on improving the quality of hemodialysis services: A qualitative study. Hemodialysis International. 2015;19(1):80-9.

3.            Henry BR, Houston S, Mooney GH. Institutional racism in Australian healthcare: a plea for decency. Medical Journal of Australia. 2004;180(10):517-20.

4.            Griffith DM, Mason, M, Yonas, M, Eng, E, Jeffries, V, Plihcik, S, Parks, B,. Dismantling institutional racism: theory and action. Am J Community Psychol. 2007;39:381-92.

5.            Paradies Y, Harris R, Anderson I. The Impact of Racism on Indigenous Health in Australia and Aotearoa: Towards a Research Agenda. Darwin: Cooperative Research Centre for Aboriginal Health; 2008. Contract No.: Discussion Paper No. 4,.

6.            Australian Indigenous Doctors’ Association. Racism in Australia’s health system. E: policy@aida.org.au: Australian Indigenous Doctors’ Association Ltd; 2016.

7.            Taylor B. Reflective Practice For Healthcare Professionals: A Practical Guide. Berkshire, England: Open University Press; 2006.

8.            Schön DA. The reflective pracitioner: how professionals think in action. New York: Basic Books; 1983.

9.            Thackrah RD, Thompson SC. Refining the concept of cultural competence: building on decades of progress. Medical Journal of Australia. 2013;199(1):35-8.

10.          Taylor K, Guerin P. Health care and Indigenous Australians: cultural safety in practice. 1st ed. South Yarra: Palgrave Macmillan; 2010.

11.          Durey A. Reducing racism in Aboriginal health care in Australia: where does cultural education fit in? Australian and New Zealand Journal of Public Health. 2010;34(S1):S87-S92.

12.          Rix E, Barclay L, Wilson S. Can a white nurse get it? ‘Reflexive practice’ and the non-Indigenous clinician/researcher working with Aboriginal people. Journal of Rural and Remote Health. 2014;4: 2679 ( http://www.rrh.org.au ).

13.          Nicholls R. Research and Indigenous participation: critical reflexive methods. International Journal of Social Research Methodology. 2009;12(2):117-26.

14.          Australian Institute of Health and Welfare. National Indigenous Reform Agreement (2019). In: AIHW, editor. Canberra: Australian Government; 2019.

15.          Commonwealth of Australia. National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing. In: Department of the Prime Minister and Cabinet, editor. Canberra: 2017.

16.          Australian Health Minister's Advisory Council's National Aboriginal and Torres Strait Islander Health Standing Committee. Culural Respect Framework 2016-2026 for Aboriginal and Torres Strait Islander Health: A National approach to building a culturally respectful health system. Canberra: Australian Health Minister's Advisory Council; 2016.

17.          Johns C. The value of reflective practice for nursing. Journal of Clinical Nursing. 1995;4(1):23-30.

18.          Stein-Parbury J. Patient and person. 2nd ed. Marrickville: Harcourt Australia; 2000.

19.          Woolgar S. Knowledge and reflexivity: new frontiers in the sociology of knowledge. Thousand Oaks: Sage Publications Inc.; 1988.

20.          Ramsden I. Cultural safety. New Zealand Nursing Journal. 1990;83(11):18-9.

21.          Cunliffe AL, Jun JS. The need for reflexivity in public administration. Administration & Society. 2005;37(2):225-42.

22.          Broussine M, Ahmad Y. The development of public managers’ reflexive capacities. Teaching Public Administration. 2013;31(1):18-28.