Developing and evaluating Birthing on Country services for First Nations Australians: the Building On Our Strengths (BOOSt) prospective mixed methods birth cohort study protocol.

BACKGROUND: With the impact of over two centuries of colonisation in Australia, First Nations families experience a disproportionate burden of adverse pregnancy and birthing outcomes. First Nations mothers are 3-5 times more likely than other mothers to experience maternal mortality; babies are 2-3 times more likely to be born preterm, low birth weight or not to survive their first year. 'Birthing on Country' incorporates a multiplicity of interpretations but conveys a resumption of maternity services in First Nations Communities with Community governance for the best start to life. Redesigned services offer women and families integrated, holistic care, including carer continuity from primary through tertiary services; services coordination and quality care including safe and supportive spaces. The overall aim of Building On Our Strengths (BOOSt) is to facilitate and assess Birthing on Country expansion into two settings - urban and rural; with scale-up to include First Nations-operated birth centres. This study will build on our team's earlier work - a Birthing on Country service established and evaluated in an urban setting, that reported significant perinatal (and organisational) benefits, including a 37% reduction in preterm births, among other improvements. METHODS: Using community-based, participatory action research, we will collaborate to develop, implement and evaluate new Birthing on Country care models. We will conduct a mixed-methods, prospective birth cohort study in two settings, comparing outcomes for women having First Nations babies with historical controls. Our analysis of feasibility, acceptability, clinical and cultural safety, effectiveness and cost, will use data including (i) women's experiences collected through longitudinal surveys (three timepoints) and yarning interviews; (ii) clinical records; (iii) staff and stakeholder views and experiences; (iv) field notes and meeting minutes; and (v) costs data. The study includes a process, impact and outcome evaluation of this complex health services innovation. DISCUSSION: Birthing on Country applies First Nations governance and cultural safety strategies to support optimum maternal, infant, and family health and wellbeing. Women's experiences, perinatal outcomes, costs and other operational implications will be reported for Communities, service providers, policy advisors, and for future scale-up. TRIAL REGISTRATION: Australia & New Zealand Clinical Trial Registry # ACTRN12620000874910 (2 September 2020).

Evolving beyond antiracism: Reflections on the experience of developing a cultural safety curriculum in a tertiary education setting.

There is an inextricable link between cultural and clinical safety. In Australia high-profile Aboriginal deaths in custody, publicised institutional racism in health services and the international Black Lives Matter movement have cemented momentum to ensure culturally safe care. However, racism within health professionals and health professional students remains a barrier to increasing the number of Aboriginal and Torres Strait Islander Health professionals. The Australian Health Practitioner Regulation Agency's Aboriginal and Torres Strait Islander Health Strategy's objective to 'eliminate racism from the health system', and the recent adoption of the Aboriginal and Torres Strait Islander peoples led cultural safety definition, has instigated systems level reflections on decolonising practice. This article explores cultural safety as the conceptual antithesis to racism, examining its origins, and contemporary evolution led by Aboriginal and Torres Strait Islander peoples in Australia, including its development in curriculum innovation. The application of cultural safety is explored using in-depth reflection, and the crucial development of integrating critical consciousness theory, as a precursor to culturally safe practice, is discussed. Novel approaches to university curriculum development are needed to facilitate culturally safe and decolonised learning and working environments, including the key considerations of non-Indigenous allyship and collaborative curriculum innovations and initiatives.

The Indigenous Birthing in an Urban Setting study: the IBUS study : A prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland, Australia.

BACKGROUND: With persisting maternal and infant health disparities, new models of maternity care are needed to meet the needs of Aboriginal and Torres Strait Islander people in Australia. To date, there is limited evidence of successful and sustainable programs. Birthing on Country is a term used to describe an emerging evidence-based and community-led model of maternity care for Indigenous families; its impact requires evaluation. METHODS: Mixed-methods prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland (2015-2019). Includes women's surveys (approximately 20 weeks gestation, 36 weeks gestation, two and six months postnatal) and infant assessments (six months postnatal), clinical outcomes and cost comparison, and qualitative interviews with women and staff. DISCUSSION: This study aims to evaluate the feasibility, acceptability, sustainability, clinical and cost-effectiveness of a Birthing on Country model of care for Aboriginal and Torres Strait Islander families in an urban setting. If successful, findings will inform implementation of the model with similar communities. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry # ACTRN12618001365257 . Registered 14 August 2018 (retrospectively registered).

Birthing on Country (in Our Community): a case study of engaging stakeholders and developing a best-practice Indigenous maternity service in an urban setting.

Developing high-quality and culturally responsive maternal and infant health services is a critical part of 'closing the gap' in health disparities between Aboriginal and Torres Strait Islander people and other Australians. The National Maternity Services Plan led work that describes and recommends Birthing on Country best-practice maternity care adaptable from urban to very remote settings, yet few examples exist in Australia. This paper demonstrates Birthing on Country principles can be applied in the urban setting, presenting our experience establishing and developing a Birthing on Country partnership service model in Brisbane, Australia. An initial World Café workshop effectively engaged stakeholders, consumers and community members in service planning, resulting in a multiagency partnership program between a large inner city hospital and two local Aboriginal Community-Controlled Health Services (ACCHS). The Birthing in Our Community program includes: 24/7 midwifery care in pregnancy to six weeks postnatal by a named midwife, supported by Indigenous health workers and a team coordinator; partnership with the ACCHS; oversight from a steering committee, including Indigenous governance; clinical and cultural supervision; monthly cultural education days; and support for Indigenous student midwives through cadetships and placement within the partnership. Three years in, the partnership program is proving successful with clients, as well as showing early signs of improved maternal and infant health outcomes.

Creating walking tracks to success: A narrative analysis of AustralianAboriginal and Torres Strait Islander nursing students' stories ofsuccess.

Australian Aboriginal and Torres Strait Islander people have higher rates of morbidity and mortality thanother Australians. One proposed strategy to improve this situation is to increase the participation ofAboriginal and Torres Strait Islander people, including Aboriginal and Torres Strait Islander nurses, inthe health workforce. Although the numbers of Aboriginal and Torres Strait Islander students under-taking tertiary nursing courses have increased, completion rates have not kept pace. The study aimedto describe Aboriginal and Torres Strait Islander nursing students' experiences of enablers for successfulcourse completion and to develop a narrative of student experience. A qualitative study using a strengths-based approach with a narrative analysis of semi-structured interview data was conducted across fourschools of Nursing in Queensland, Australia. Eight final-year Aboriginal and Torres Strait Islander nursingstudents volunteered to participate in the study. A collective story with the overarching plotline Creatingwalking tracks to success was developed. Six threads of experience emerged: Making a difference, Valu-ing Indigeneity, Healing strength of connections, Resisting racism, Embracing support, and perseveringtowards completion. Key success factors included resilient attributes, building supportive connectionsand having positive expectations of the future, along with sustained institutional support from Aboriginaland Torres Strait Islander nurse academics and clinicians. Development of tailored resilience-buildingtraining for Aboriginal and Torres Strait Islander nursing students and appointment of Aboriginal andTorres Strait Islander academics in Schools of Nursing that include such students may facilitate futuresuccessful completions in other programs.

Indigenous Australians' participation in pre-registration tertiary nursing courses: a mixed methods study.

Indigenous nurses have the potential to improve access to health services for Indigenous people by ensuring that services are culturally safe and respectful of Indigenous peoples' needs. Therefore, developing a well-educated Indigenous nursing workforce is one way to improve the poor health outcomes of Indigenous Australians. A mixed methods study was undertaken to determine the current rates of enrollment, progression and completion of Indigenous nursing students in Australia and to explore student and staff perceptions of barriers to completion and strategies for success. The results indicate that the national average completion rates are 36.3% for Indigenous nursing students and 64.6% for non-Indigenous nursing students - an average difference of 28.3%. Indigenous nursing students and academics identified barriers to completion, which were similar to those identified in previous research. Success strategies, however, revealed the importance of individual student characteristics; academics' knowledge, awareness, and understanding; relationships, connections, and partnerships; institutional structures, systems, and processes; and, family and community knowledge, awareness, and understanding. This paper offers an overview of the integration and interpretation process that makes up the final phase of a mixed methods study.

Through a critical lens: indigenist research and the dadirri method.

Indigenous scholars have addressed the problematic nature of research by adopting methodologies that fit well with their communities and that relate effectively and culturally with how knowledge is shared to give indigenous people a voice. In this article we discuss Dadirri, an indigenous research method and way of life, as a vital research framework, connecting it to other relevant political and critical methodologies such as Freire's transformative education process and Habermas' theory of communicative action. In doing so, we illustrate how this methodology provides a significant framework for indigenous researchers undertaking liberatory studies that promote change.

Are Australian Universities Perpetuating the Teaching of Racism in Their Undergraduate Nurses in Discrete Aboriginal and Torres Strait Islander Courses? A Critical Race Document Analysis Protocol.

Systemic racism has a profound negative impact on the health outcomes of Australia's First Nations peoples, hereafter referred to as Aboriginal and Torres Strait Islander peoples, where racism and white privilege have largely become normalised and socially facilitated. A national framework is being mobilised within the tertiary-level nursing curriculum to equip future health professionals with cultural capabilities to ensure culturally safe, equitable health care for Aboriginal and Torres Strait Islander peoples. In 2019, nurses comprised more than half of all registered health professionals in Australia, and current national standards for nursing state that Australian universities should be graduating registered nurses capable of delivering care that is received as culturally safe. It is therefore critical to evaluate where learning objectives within nursing curricula may lead to the reinforcement and teaching of racist ideologies to nursing students. This protocol outlines a framework and methodology that will inform a critical race document analysis to evaluate how learning objectives assert the social construction of "race" as a tool of oppressive segregation. The document analysis will include each discrete Aboriginal and Torres Strait Islander health course within all undergraduate nursing programs at Australian universities. The approach outlined within this protocol is developed according to an Indigenous research paradigm and Colonial Critical Race Theory as both the framework and methodology. The purpose of the framework is a means for improving health professional curriculum by reducing racism as highlighted in nation-wide strategies for curriculum reform.

Are We Teaching Nurses to Be Racist towards Aboriginal and Torres Strait Islander Peoples? A Critical Race Document Analysis of Discrete Aboriginal and Torres Strait Islander Health Courses.

BACKGROUND: Racism is responsible for health inequity and the harm perpetrated upon Aboriginal and Torres Strait Islander peoples by white institutions, building on attitudes and beliefs dominated by assumptions of white superiority. The National Aboriginal and Torres Strait Islander Health Curriculum Framework 'Curriculum Framework', released in 2014, was introduced to provide a framework for nursing programs and included the introduction of discrete Aboriginal and Torres Strait Islander health courses to draw attention to the relationship between racism health outcomes of Aboriginal and Torres Strait Islander peoples within health care settings. METHODS: Using an Indigenist research paradigm with Colonial Critical Race Theory as the methodology and framework, this study presents a document analysis of discrete Aboriginal and Torres Strait Islander health courses taught in undergraduate nursing programs at 31 Australian Universities. RESULTS: This work draws on the collective activism of Aboriginal and Torres Strait Islander nurses in challenging the systemic racism embedded in the Australian nursing curriculum. We demonstrate the utility of the Racial Segregation Audit Tool (RSAT), as an innovative approach to identify and respond to racism embedded in course learning outcomes. CONCLUSIONS: This study explores and uncovers how the learning outcomes assert the social construction of race as a tool of oppressive segregation.

Indigenous-led First Peoples health interprofessional and simulation-based learning innovations: mixed methods study of nursing academics' experience of working in partnership.

Background: Collaborative, Indigenous-led pedagogical and research approaches in nursing education are fundamental to ensuring culturally safe curriculum innovations that address institutional racism. These approaches privilege, or make central, Indigenous worldviews in the ways healthcare practices are valued and assessed. With the aim of informing excellence in cultural safety teaching and learning, and research approaches, this study draws on the experiences and key learnings of non-Indigenous nursing academics in the collaborative implementation of First Peoples Health interprofessional and simulation-based learning (IPSBL) innovations in an Australian Bachelor of Nursing (BN) program.Methods: An Indigenous-led sequential mixed method design was used to investigate non-Indigenous nursing academics' experiences in the design, development and delivery of two IPSBL innovations. A validated survey (the Awareness of Cultural Safety Scale, (ACSS)) was administered to nursing academics before and after the innovations were delivered. Phenomenological interviews were also conducted following the implementation of the innovations.Results: Of the 27 staff involved in the delivery of the innovations, six nursing academics completed both pre-and post-surveys (22%). Nine (33%) participated in phenomenological interviews. There was a non-significant trend towards improved scores on the ACSS following the delivery of the innovations. Nursing academics' perceptions of the innovations' relevance to their practice were enhanced. An increased awareness of culturally safe academic practices was reported among those actively involved in innovations.Impact statement: Indigenous-led approaches in teaching and research promote excellence within mandatory cultural safety education for nurses and midwives.Conclusions: This study confirms the importance of educating the educators about cultural safety in teaching and learning, and research approaches. It also provides important insights into how non-Indigenous nursing academics can work within Indigenous-led pedagogical and research approaches to design culturally safe curriculum innovations.

Measuring effectiveness of cultural safety education in First Peoples health in university and health service settings.

Background: Cultural Safety is a mandatory training requirement for the 16 regulated health practitioners in Australia. Tools measuring outcomes need to be appropriate for different education and training contexts.Aim: To test refinements to the 25 item Cultural Capability Measurement Tool (CCMT).Methods: Framed by decolonising and relational ways of knowing, being, and doing in the tool development process. New items of the CCMT were generated through engagement with key knowledge holders. New items were piloted with expert reviewers and modified accordingly to produce a 41-item scale. Two online surveys conducted with 875 students and then 276 health professionals were collected for analysis. Exploratory factor analysis and a parallel analysis were conducted.Results: The newly named Ganngaleh nga Yagaleh (GY) tool contained 28 items loaded on 3 factors accounting for 47.95% of variance. Factor 1 (Commitment to Culturally Safe Practice; α = .89) comprised 12 items, Factor 2 (Understanding of History and Power; α = .86) contained 9 items, and Factor 3 (Attitudes, Values, and Beliefs; α = .52) contained 7. Total scale reliability was good (α = .87).Impact statement and conclusion: The GY Scale can be used in education and practice settings. Challenges remain about how educational providers and health services approach cultural safety as a life-long learning journey, and how education and clinical practice embed cultural safety standards. Future directions for use of the GY tool include expanding it for use in other contexts and more explicit separation of what is emerging as a separate scale the 'Keeping Culture Strong' scale which evaluates the unique learning experiences of First Peoples.

Achieving cultural safety for Australia's First Peoples: a review of the Australian Health Practitioner Regulation Agency-registered health practitioners' Codes of Conduct and Codes of Ethics.

Objective Health practitioners' Codes of Conduct and Codes of Ethics articulate practice standards across multiple domains, including the domain of cultural safety. As key tools driving individual practice and systems reform, Codes are integral to improving health outcomes for Aboriginal and Torres Strait Islander peoples. It is, therefore, critical that their contents specify meaningful cultural safety standards as the norm for institutional and individual practice. This research assessed all Codes for cultural safety specific content. Methods Following the release of the Australian Health Practitioner Regulation Agency's (Ahpra) Health and Cultural Safety strategy 2020-25, the 16 Ahpra registered health practitioner Board Codes of Conduct and professional Codes of Ethics were analysed by comparing content to Ahpra's new cultural safety objectives. Two Codes of Conduct, Nursing and Midwifery, met these objectives. The Aboriginal and Torres Strait Islander Health Practitioners Code partially met these objectives. Results Most Codes of Conduct (14 of 16) conflated Aboriginal and Torres Strait Islander peoples with culturally and linguistically diverse (CALD) communities undermining the sovereignty of Australia's First Peoples. Eleven professions had a Code of Ethics, including the Physiotherapy Code of Conduct, which outlined the values and ethical principles of practice commonly associated with a Code of Ethics. Of the 11 professions with a Code of Ethics, two (Pharmacy and Psychology) articulated specific ethical responsibilities to First Peoples. Physiotherapy separately outlined cultural safety obligations through their reconciliation action plan (RAP), meeting all Ahpra cultural safety objectives. The remaining eight advocated respect of culture generally rather than respect for Aboriginal and Torres Strait Islander cultures specifically. Conclusions The review identified multiple areas to improve the codes for cultural safety content for registered health professions, providing a roadmap for action to strengthen individual and systems practice while setting a clear regulatory standard to ensure culturally safe practice becomes the new norm. It recommends the systematic updating of all professional health practitioner Board Codes of Conduct and professional Codes of Ethics based on the objectives outlined in Ahpra's Cultural Safety Strategy. What is known about the topic? Systemic racism and culturally unsafe work environments contribute to poor health outcomes for Aboriginal and Torres Strait Islander peoples. They also contribute to the under-representation of Aboriginal and Torres Strait Islander peoples in the health workforce, denying the system, and the people who use and work in it, much needed Indigenous knowledge. Creating a culturally safe healthcare system requires all health practitioners to reflect on their own cultural background, to gain appreciation of the positive and negative impacts of individually held cultural assumptions on the delivery of healthcare services. Competence in cultural safety as a required standard of practice is therefore essential if broad, sustainable and systemic cultural change across the health professions and ultimately across Australia's healthcare system is to be achieved. Given that Codes of Conduct and Codes of Ethics are integral in setting the practical and moral standards of the professions, their contents with respect to cultural competence are of great importance. What does this paper add? A review of this type has not been undertaken previously. Following the establishment of the Ahpra Aboriginal and Torres Strait Islander Health Strategy Group, release of Ahpra's 2018 Statement of intent, and the 2019 Aboriginal and Torres Strait Islander Health and Cultural Safety strategic plan and Reconciliation Action Plan, we analysed the content of each of the 16 registered health professions Codes of Conduct and Code of Ethics looking for content and guidance in accordance with the new national cultural safety definition. Several opportunities to improve the Codes of Conduct and Codes of Ethics were identified to realise the vision set out in the statement of intent including through the application of the National Law. This analysis provides a baseline for future improvements and confirms that although some current health practitioner Codes of Conduct and Codes of Ethics have begun the journey of recognising the importance of cultural safety in ensuring good health outcomes for Australia's Indigenous peoples, there is broad scope for change. What are the implications for practitioners? The gaps identified in this analysis provide a roadmap for improvement and inclusion of Aboriginal and Torres Strait Islander Health and cultural safety as a required standard in Codes of Conduct and Codes of Ethics for all registered health practitioners. Although it is recognised that Codes alone may not change hearts and minds, codifying the clinical competency of cultural safety provides a portal, and a requirement, for each individual practitioner to engage meaningfully and take responsibility to improve practice individually and organisationally.

A call for action that cannot go to voicemail: Research activism to urgently improve Indigenous perinatal health and wellbeing.

In this call to action, a coalition of Indigenous and non-Indigenous researchers from Australia, Aotearoa New Zealand, United States and Canada argue for the urgent need for adequately funded Indigenous-led solutions to perinatal health inequities for Indigenous families in well-resourced settler-colonial countries. Authors describe examples of successful community-driven programs making a difference and call on all peoples to support and resource Indigenous-led perinatal health services by providing practical actions for individuals and different groups.

Increased numbers of Australian Indigenous nurses would make a significant contribution to 'closing the gap' in Indigenous health: what is getting in the way?

The provision of a well trained and culturally safe health workforce is critical to the alleviation of health inequities for Australian Indigenous peoples. Educating and graduating significant numbers of Indigenous registered nurses is one way the 'Close the Gap' initiative succeeds. Indigenous nurses bring a set of unique skills, knowledge and understanding to health service delivery. Their contribution has the potential to enhance future outcomes for Indigenous people by improving access to health services, ensure services are culturally appropriate and respectful, and assist non-Indigenous nurses to deliver culturally appropriate care. This paper discusses the background to the current numbers of Indigenous undergraduate nursing students enrolled in and completing tertiary nursing courses, with a focus on Queensland nursing programs. A range of identified barriers impede Indigenous nursing students' successful completion of their studies. We propose recommendations for education, research and employment to help overcome these problems, and ensure greater Indigenous participation in the nursing workforce.

Tjirtamai--'to care for': a nursing education model designed to increase the number of Aboriginal nurses in a rural and remote Queensland community.

In 2009, a nursing education model was locally designed and delivered to support the interest of a group of Aboriginal community members living in a rural and remote town in Queensland, specifically to prepare for entry into further nursing education. Named 'Tjirtamai' by the traditional owners of the area, the program was offered in recognition of the challenges faced by Aboriginal people when they enter nursing education courses and as a way to increase the local number of Aboriginal nurses. This program, while funded by the Government, had unprecedented support and involvement from both the local Aboriginal and wider community. The model offered multiple exit points, assistance with financial and other known challenges for Aboriginal and Torres Strait Islander students, and included contextualised literacy and numeracy. Of the 38 Aboriginal students who enrolled in the course, 26 students completed. Of those students, 18 have since enrolled in a bachelor degree in nursing while another 4 enrolled in a diploma of nursing. This paper provides an overview of the course and its outcomes.

The influence of yarning circles: A cultural safety professional development program for midwives.

BACKGROUND: A university educated, First Peoples health workforce is paramount to improving health outcomes for Australia's First Peoples. However, a significant gap exists between the academic success of First Peoples and non-Indigenous students. The facilitation of culturally safe learning and teaching environments by academics is essential to closing this gap. There is little research on midwifery academics' understanding of Cultural Safety and the translation of this understanding in learning and teaching. OBJECTIVES: To explore the influence of yarning circles within a professional development program to enhance midwifery academics' awareness of Cultural Safety. METHODS: A six-month staff development program which consisted of two workshops and a series of yarning circles was offered to all midwifery academics. Eight participants agreed to be interviewed after completion of the program. Interviews were transcribed verbatim, read and re-read, and analysed using a six staged thematic analysis process. RESULTS: Six key themes centred on participants' Sense of Belonging, Sense of Safety, Sense Knowing, Sense of Support, Sense of Difference, and Sense of Challenge were identified. These concepts were supportive of participants' developing awareness of Cultural Safety. CONCLUSION: Yarning circles can encourage midwifery academics' awareness of Cultural Safety. Awareness is the first step towards becoming culturally safe. Yarning provided a safe and supportive space for challenging discussions and reflective learning about racism, white privilege, and difference. Midwifery academics described steps they could take to promote Cultural Safety in the classroom.

Cultural safety continuing professional development for midwifery academics: An integrative literature review.

BACKGROUND: Awareness of cultural safety by midwifery academics is integral to the provision of a safe learning and teaching environments, use of effective pedagogies, and academic success of Indigenous midwifery students. However, little is known about the scope and efficacy of continuing professional development activities that aim to develop awareness of cultural safety by midwifery academics. AIMS: To conduct an integrative review of the literature with respect to the scope and efficacy of professional development interventions that aim to increase awareness of cultural safety by midwifery academics. METHODS: An integrative review of peer-reviewed literature from 2005 -2017 was undertaken. Documents were assessed using the Critical Appraisals Skills Program (CASP) guidelines. Concepts were mapped thematically. RESULTS: Results are reported and discussed using key themes identified in the analysis. Five broad themes emerged from the analysis of studies. The themes were named: Cultural Terms, Knowledge of Culture, Cultural Education, Cultural Aspirations and Culture in Curricula. CONCLUSIONS: Midwifery academics requireprofessional development to raise their awareness of cultural safety in order to adopt effective learning and teaching practices. There is currently no agreed best practice framework to support awareness of cultural safety for midwifery academics. The philosophy of midwifery practice has many synergies with the principles of cultural safety. Cultural safety needs to be embedded into professional development plans for midwifery academics.

Evaluating awareness of Cultural Safety in the Australian midwifery workforce: A snapshot.

PROBLEM: There are no validated tools to measure midwives' awareness of Cultural Safety. BACKGROUND: Cultural Safety is an important component of midwifery practice. Measurement can inform practice and evaluate professional development strategies. AIM: To adapt and evaluate the Awareness of Cultural Safety Scale with the midwifery workforce. METHODS: An online survey was distributed to members of Australian College of Midwives and Congress of Aboriginal and Torres Strait Islander Nurses and Midwives. Measures included the Awareness of Cultural Safety Scale - Revised, Self-assessment of Cultural Knowledge and Perceptions of Racism scales. FINDINGS: The revised Awareness scale had a Cronbach's alpha of 0.87. Principal Component Analysis with varimax rotation produced a three-factor structure accounting for 67% of variance. Awareness scores correlated with Self-assessment of Cultural Knowledge (r=0.22 p<0.03) and Perceptions of Racism (r=0.62 p<0.001) scales. Educators scored significantly higher on awareness compared to clinicians (t (1,80)=-3.09, p=0.003). Perceptions of Racism predicted Awareness of Cultural Safety scores (F (2,87) 29.25, adjusted r square=0.39 p<0.001 95% Confidence Interval=1.09, 1.93). DISCUSSION: The revised scale was a reliable and valid measure of Cultural Safety across a diverse sample of midwives. Midwives working in education settings have a higher awareness of Cultural Safety than clinical peers. CONCLUSION: The Awareness of Cultural Safety Scale can be used with midwives across practice settings. Professional organisations and education providers need to promote the professional responsibilities of midwives towards Cultural Safety in clinical practice and education.