9th August 2019

Methodology to Detect Institutional Racism in Australian Healthcare Standards

By DrMJLock


This is Blog #2 in the series The Structuration of Institutional Racism in Australia’s Governance of Safety & Quality in Health Service Standards (see Blog #1). My aim here is to detail the methodology of structuration theory, policy trajectory, Foucault, and corporate document analysis.

Anthony Giddens’ Structuration Theory (AGST)

Structuration theory is defined as the ‘structuring of social relations through space and time in virtue of the duality of structure’ (Giddens 1984) and this can be transformed into a theoretical schema (below).

In simplified terms, ‘structuring’ = reforms and restructures (for example, the National Safety and Quality Health Services Standards (NSQHS Standards) is about structuring health services. Then, ‘social relations’ = corporate governance, ‘space’ = organisations, and ‘time’ = Acts. The ‘duality of structure’ is the dynamic interplay between agents in ‘participation’ and social norms in ‘citizenship’. Therefore, the theoretical statement for this critique is: ‘NSQHS Standards influencing the corporate governance of organisations through Acts in virtue of the duality of participation and citizenship’. At this stage, I just want to be clear that the methodology of the critique is theoretically driven.

Employing Giddens’ (1984) perspective, we can investigate a specific structuration, the interactive and dynamic duality of whiteness and “race” in American society.

Teresa J. Guess

The Policy Trajectory Method

The concept of ‘routine’ and ‘routinization’ are central to structuration theory because Giddens saw how deeply embedded social rules (i.e. institutions) are routinely incorporated into daily life. His famous example is language where we routinely talk to one another (the inter-personal interaction level, see the figure above) yet we would struggle to consciously explain the rules and resources (structure) of language – the rules of grammar, syntax, spelling, etc. and the resources used to create and re-create language. Based on my experience in the healthcare system, a routinised activity in Australia is policy development processes and their products – like the NSQHS Standards.

The policy trajectory means that a current policy – the NSQHS Standards – has an origin – the Quality in Australian Health Care Study. In between the current policy and the origin are several policy steps. The figure, below, shows the number of points from the Quality in Australian Health Care Study to the NSQHS Standards 2 in 2017 (left hand side), and the number of points from the Social Justice Report – Health to the National Framework for Continuous Quality Improvement in Primary Health Care for Aboriginal and Torres Strait Islander People 2018-2023. The key message is that there are many points in the pathway of a policy trajectory.

NSQHS Standards Policy Trajectory

Tracking Aboriginal Cultural Voice

A critical aspect of the policy trajectory methodology is to assess the points in the pathway where the cultural voice of First Nations Australians is referenced. The phrase ‘cultural voice’ is defined as the human cultural perspectives of First Nations Australians. Cultural voice can be tracked in policy documents by searching for the key words ‘Aboriginal’, ‘Torres Strait Islander’, or ‘Indigenous’ and these can be found in the cultural identity of committee members, as key words in the body text, and in the titles of documents in the reference list. It’s a straightforward task to do a keyword search but the results can be really surprising. For example, the First Nations health policy trajectory (right hand side, above) is very noisy with those keywords but the NSQHS Standards policy trajectory (left hand side, above) is almost silent – why?

Foucault – A Triad of Power, Knowledge and Discourse

The silence of Aboriginal cultural voice in the NSQHS Standards policy trajectory is a function of the power, knowledge and discourse triad I used the ideas of French philosophy Michel Foucault to inform my analysis of the holistic concept of Aboriginal health: the power, knowledge, discourse triad. The word ‘discourse’ means the ‘normal’ way of speaking or writing about a topic that defines the reality of that topic. For example, the ‘normal’ way of writing about healthcare governance excludes the cultural voice of First Nations Australians. Therefore, over time, the ‘knowledge’ (‘facts, information, and skills acquired through experience and education’) of governing a healthcare organisation excludes cultural knowledge. Therefore, knowledge and power are intertwined, because a health professionals power (capability of doing things) to enable cultural safety is limited by the absence of discourse about it in healthcare governance literature.

An archaeology of knowledge (Foucault 1972) about race and whiteness provides a useful strategy for uncovering ways in which symbolic meaning systems, (e.g., “race” and whiteness) define, legitimize, and reproduce themselves across generations

Teresa J. Guess

Summary of The Methodology

Structuration Theory + Policy Trajectory + Cultural Voice + Foucault + Textscape = the methodology to detect institutional racism in Australian healthcare standards.

My analysis is inspired by Teresa Guess’ (2006) publication ‘The Social Construction of Whiteness: Racism by Intent, Racism by Consequence‘. I’ll draw on Guess’ work throughout this analysis. What I really liked was one of her opening statements (in the context of American racial relationships), ‘The question raised by the black/white binary paradigm is: to what extent has sociology participated in knowledge creation that results in preservation or normalization of America’s racial hierarchies?’ and that’s exactly the perspective I take with policy document analysis.

To what extent has healthcare governance participated in knowledge creation that results in the preservation or normalisation of Australia’s racial hierarchies?

Of course, ‘healthcare governance’ is written about like it was a person with decision making power (which is the mistake of reification). Therefore, in this analysis I unpack the phrase ‘healthcare governance’ in an empirical way where, as I go through the process of analysing the policy documents, the mechanics, mechanisms, structures, processes, practices and people of healthcare governance become visible. For example, the Australian Commission on Safety and Quality in Health Care (ACSQHC) is a keystone committee – a ‘structure’ – of healthcare governance.

The result of racism by intent has overtime informed institutional cultures and practices that rest on assumptions of white superiority over non-white ethnic groups.

Teresa J. Guess

Policy Documents form a ‘Textscape’

Why policy documents? Well, I’ve never been at the table of any decision-making committee in Australian healthcare. I’m not a medical professional, or epidemiologist, or a professor of either of those disciplines and so it has become quite evident through the course of policy document analysis that the term “expert” is a way to exclude Aboriginal people who do not have those qualifications. Or are “experts” due to executive bureaucratic power careers.

The closest that I can get to these keystone committees is to read what they authorise to be published – their policy documents. And I find it fascinating! To me, due to my sociological training, I see the messages written into policy documents as forming a ‘textscape’: the creation of patterns of meaning through the knitting together of different writing on the same topic. I read policy documents because they are ‘totemic objects’ produced by ‘coalitions of elites’ worthy of analysis because ‘beneath their flat surface run the broad currents that underlie aspects of public life.’ (Sullivan 2012)

Textscape: the creation of patterns of meaning through the knitting together of different writing on the same topic.

In other words, when I’ve read, and re-read, all the policy documents in the policy trajectory (see the figure, above) a textscape of meaning evolves where I can ‘look’ into it and see signs, symbols, and signals of meaning. Because all of the policy documents in the NSQHS Standards Policy Trajectory (left hand side) completely excluded Aboriginal people, how can I not see that as a political act? Policy documents are ‘themselves political acts’ that ‘carry meanings representative of the struggle and conflict of their production’ (Gale 1999), and ‘published sources of knowledge about Aboriginal people are contested knowledge and ‘living texts’ (Kwaymullina et al. 2013). In contrast, in First Nations Policy trajectory (right hand side), the decision-making processes is also dominated by non-Aboriginal bureaucrats and executives – how is that not a political process? In conclusion, this methodological summary shows how institutional racism can be detected in the seemingly banal pages of policy documents.

Racism by consequence then is reflected in differential educational opportunities, economic differentials between whites and non-whites, residential segregation, health care access, and death rate differentials between whites and non-whites.

Teresa J. Guess

The use of structuration theory, policy trajectory, cultural voice, Foucault and textscape combine to be an analytical net that can capture the hidden memes of institutional racism.

Lock, M.J. (9 August 2019) “Methodology to Detect Institutional Racism in Australian Healthcare Standards: Blog Post #2 in ‘The Structuration of Institutional Racism in Australia’s Governance of Safety & Quality in Health’. Newcastle: Committix Pty Ltd.