In a Heartbeat: Animation as a Tool for Improving Cultural Safety in Hospitals

Abstract

This chapter describes the development of an animated video to help clinicians become more aware of and sensitised to the cultural needs of Indigenous and First Nations consumers. Addressing a critical issue that faces many patients from the non-dominant culture, the QUT Design Lab team worked closely with an Aboriginal nurse who highlighted the critical need to gently make clinicians aware of their potential racism and cultural bias when dealing with consumers. The chapter tells the story of the development of the animation, from its initial conception as a trilogy of videos through various issues, into its final product as a single video with a singular animation style that is now being successfully used for clinician training.

The quietness is loud with beeps, hushed conversations, rushed steps and rolling beds. I am half conscious, in a bed, being pushed out of the ambulance, through clean corridors, wards, and reception rooms full of unfamiliar faces. The nurse by my side is very nice, I think he is good looking too, but that might have been a consequence of my concussion. My tooth hurts, my hand hurts, I’m not even mentioning my head. I can’t remember anything that happened that afternoon, or how I ended up fainting in the kitchen. Unfamiliar faces everywhere, lots of questions, a few answers. I came alone in the ambulance, my partner had to stay with the kids. No family around, 3am in the morning of Mother’s Day Sunday, not fair to call on any friend for help. I think of my 5yo who was very excited to cook breakfast for his mum, who will now, if lucky, have breakfast in bed—a hospital bed. The thought makes me sad, but glad at the same time: I now remember my kids, who and where they are.

Time in hospital is lonely, confusing and full of anxiety for most patients, as this reflection by the first author shows. In Australia, First Nations (FN) patients—as well as patients from non-dominant cultures—deal with a heightened level of discomfort when in hospitals as, on top of all the other uneasy feelings, they also often feel culturally unsafe. Racism, in its many forms, has negative impacts on the treatment of Aboriginal and Torres Straits Islander patients in Australia [1, 2]. Racism and unconscious bias not only obstruct access to service, but also increase distress and anxiety for patients and clinicians [3]. While patients suffer the direct and indirect consequences of racism, reports show that experienced and well-intentioned clinicians also feel uncomfortable and sometimes anxious when treating First Nations patients [4].

Anderson [5] defines “access to service” in healthcare as going beyond the existence of local and affordable services to include cultural safety and appropriateness of service. Cultural Safety has been introduced as a concept in health care by Dr. Irihapeti Ramsden, in New Zealand in the late 1980’and early 1990s, “in response to the poor health status of Maori” and the need for health services to change substantially [6]. Since then, the concept has been embedded into nursing and healthcare charters and into some formal health education efforts. Despite updates and changes applied to cultural concept definitions, there are two core ideas that should guide any effort in applying the concept. The first one relates to the original definition of Cultural Safety by Ramsden [7] as “the effective nursing of a person/family from another culture by a nurse who has undertaken a process of reflection on own cultural identity and recognizes the impact of the nurses’ culture on own nursing practice” (n.p.). The second one is the understanding that cultural safety can only be determined by the people receiving care—specifically Aboriginal and Torres Strait Islander individuals, families, and communities, for the scope of this project. These two premises are important as the former defines the role of the care provider to perceive and understand their own biases and power role; the latter acknowledges that the feeling of safety cannot be determined externally, only the patients—receivers of care—can state their own sense of safety, and this will vary according to each individual.

This focus on the individuals and their particular needs, and the concern with the power relations in health care is reflected in Ramsden’s distinction between cultural safety and transcultural nursing, where she points out that the concept of transcultural nursing is centred on differentiating people’s ‘cultures’, usually in a stereotypical way, and assuming that the culture of nurses (usually based on an Anglo, Western training and perspective) is the ‘normal’ culture, the one that is valid and must be followed [8,9,10].

Later discussions prioritise the need to deal with the underlying social causes of ethnic health inequities in the health system—such as institutional racism and unconscious bias—in order to mitigate these inequities [3, 11, 12]. These studies recognise the importance of cultural competency and cultural safety in health practices to achieve more equitable health care services. In line with this, the National Scheme’s Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020–2025 defines culturally safe practices as:

the ongoing critical reflection of clinicians and systems knowledge, skills, attitudes, practicing behaviours and power differentials in delivering safe, accessible and responsive healthcare free of racism. [13]

In 2021, as part of the HEAL innovation program, our team was approached by Kirsty Leo, an Aboriginal Woman and QLD Health nurse who has been fighting for the right to cultural safety in hospitals for years. The intention of her project was to create one more channels through which hers and other First Nations voices can be expressed and heard—to develop a tool to help with raising awareness towards cultural safety in hospitals that could be also used for training and demonstrations. Kirsty’s underlying idea for the tool was to show that often, despite the best of intentions, training, attention, and care deployed by most clinicians, unconscious bias and structural racism unintentionally persists in their relationships with FN patients, causing these patients to feel uncomfortable and culturally unsafe.

We devised a collaborative research project to approach cultural safety in hospitals by creating a short, animated video as a pilot to demonstrate and raise awareness. The video was co-created with the clinicians as the main audience. This project navigates the concepts of cultural awareness and cultural sensitivity, building up to the definition, and potential impact of cultural safety. The final video demonstrates the cultural barriers and anxieties from the clinician’s and patient’s perspectives, provides clear definitions and suggests a pathway to overcoming these barriers through building cultural awareness, cultural sensitivity and an understanding of cultural safety.

The pilot is intended to serve as a provocation piece by initiating discussion amongst the healthcare practitioners on what is the best way to provide information training and support to improve clinicians cultural awareness and sensitivity. We hope, this will help to eventually enable more culturally safe treatment environments.

The QUT Design Lab, with its design for change vision and transdisciplinary approach was able to put together a highly consultative team with capacity to work on short-form video design and production, film and television knowledge, communication advice, visual communication, animation, and writing craft. Associate Professor Sean Maher was involved in the project from its earliest stages, overseeing and recruiting MPhil animation student Thalia Brunner, who joined the team to execute the animations. Thalia embraced the opportunity to employ her skills as an animator to an industry outside of entertainment, showcasing the value they have as an effective communication tool for a complex subject matter. Professor Sue Carson brought her experience with Australian cultural tourism, transcultural communication, and creative writing. Dr. Manuela Taboada’s contribution was leadership across the many visual communication elements, spanning illustration and typography to collaborative decolonial design.

Even though we had a transdisciplinary and multicultural team with the minds and the hearts for delivering the project—technical and philosophical backgrounds and experience to reframe the problem and work collaboratively through potential solutions—we were highly cognizant that we comprised a team of non-Indigenous academics to tell an Indigenous story [14].

Kirsty Leo’s involvement was therefore decisive in the partnership, encouraging our participation in the project and welcoming a co-design-based methodology. Her role was more than that of a client; through her expertise and Indigenous perspective she acted as the team’s mentor and guide throughout the process. Through Kirsty’s vision and insights, the team was able to overcome some of the most difficult co-design and critique sessions.

1 Why Animation?

Animation was a natural choice as the media for this project as through animation it is possible to override certain constraints of reality and have complete control over the visual style and aesthetics of the outcome, allowing the team to construct a more compelling story which seamlessly incorporates textual information, illustration, and movement. Animation allows for a lot more flexibility and reduced production costs when compared to creating live-action videos.

Having total control over visual style and aesthetics of the video makes animation an excellent media when communicating sensitive complex issues such as cultural safety. In our case, for instance, it was possible to draw a character that was as androgynous as possible, avoiding the association of the clinician with any gender. Animation enabled the looks of the characters to suit the intended message. The toned down colours and contrast of the background settings helped emphasize character interactions, thoughts and emotions [15]. One of the most striking features of the video is the “bias curtain”, which would not have been possible to create with the desired characteristics (movement of the words, transparency, ability for the viewer to read) if not using animation.

Animation is described as a storytelling media that is capable of generating strong emotional connections throughout diverse audiences (age, gender, culture), enabling feelings of empathy and exotopy (where viewers can see themselves outside of themselves as they identify with animation characters) [16]. Such engagement is enabled by the symbolic representations that illustrated characters allow for, instead of relying on actors and directly connecting their identities to the topic or positioning of the video.

Most importantly, animations are highly memorable, as they combine a defined colour palette with usually specific illustration styles, motion, rhythm, and camera movements that, together can permeate the imaginary in a deeper way than live-videos or static images [17]. The combination of these elements with a thought-provoking narrative turn animations into real catalysts for important conversations and institutional change, which is one of the main objectives of this project.

2 Re-Defining the Problem and Designing an Intervention

The first step on this project was to translate the client’s needs into a workable brief with clear methods, outcomes, and timelines. This was initiated in the earlier phases of the project by A/Prof Sean Maher, Prof Sue Carson and Thalia Brunner responding to Kirsty Leo’s requests, with continuous refinement led by Dr. Manuela Taboada to achieve a design-led solution.

Most importantly, the working brief contained Kirsty Leo’s expectations for the project, and her vision for the animation style and content, specific statements, and precise wording to be included in the videos. This information was communicated through a series of meetings and regular follow-up email exchanges that structured the flow of information sharing.

Kirsty declared some specific words with which she would like to introduce the work:

As a First Nation clinician I have had the privilege to work side by side with hundreds of clinicians across Queensland hospitals. Throughout my career my friends & colleagues have shared with me many of their own clinical experiences and anxieties (worries, concerns) when working with FN consumers.

This statement is the point of departure for the content of the video, and makes clear Kirsty’s position, perspective, and experience. This statement, in combination with a well-defined brief in terms of style and storyline, were used by the team to refine the visuals and techniques to be used to produce, what initially would be three short, animated videos on Cultural Awareness, Cultural Sensitivity and Cultural Safety.

3 Step 2: Working Together towards a Script and a Visual Style

In her briefing to the team, Kirsty detailed the content of the three videos, including specific words related to unconscious bias that she wanted included in the story:

Kirsty Leo’s suggestions for Video script, style and experiences:

CULTURAL AWARENESS [video 1]

Hospital scene and hospital noises.

I think we will have to introduce Cultural Safety at the start of the first video- my experience the term does get used interchangeably and there is general confusion and misunderstanding of this framework- it is wordy but critical to provide context to the videos and broaden the understating of cultural safety in the health system. Kirsty Leo.

As the clinician walks towards the hospital bed show quote:

The process towards achieving Cultural Safety within clinical practice can be evident as a stepwise progression from cultural awareness through to cultural sensitivity and on to Cultural Safety. However, the terms cultural awareness and cultural sensitivity are not interchangeable with Cultural Safety. These are separate concepts“ [10].

CULTURAL SENSITIVITY [video 2]

Video 2 should be about the clinician’s experience—breathing/heart rate sounds could be increased—hospital noise decreases while looking at the curtain blocking the patient to them.

I think to avoid any ethics issues we can keep this video more about the clinicians realising what Cultural sensitivity is- they could look away from the curtain of words/example to look at the below statement then look back at the curtain.

Some words could be added to the curtain to refer to the clinician’s self-reflection and thoughts.

CULTURAL SAFETY [video 3]

The third Video should be about the experience of the First Nation patient—the view could be from the bed now to the curtain of words perhaps darkening or coming in on them—Breathing and heartbeat are intense, footsteps loud then could black-out or have the curtain or something like that to show the below statement on Cultural Safety. This will leave the viewer with an impact and something to think about.

Words to be used in the videos related to unconscious bias, as specified by Kirsty:

Cultural Awareness (video 1)
Sovereignty	Critical Race Theory	Stolen wages
Colonisation	Treaty	Exemption cards
Captain cook discovered Australia	Frontier wars	Get over it
Truth telling	Massacres	Burden of disease
Australia day change the date	Institutional racism	Burden on community
Uluru statement from the heart	Research Grants	Crime rates
Decolonisation	White Australian policy	Reconciliation
Sorry day	Stolen generation	Youth justice
Black deaths in custody	Black livers matter	The Australian dream—Adam Goodes
Government handouts	Family violence	Addiction

Cultural Sensitiveness (video 2)
My own experiences	My own Education	Media Coverage
Unconscious bias	White privilege	Generational knowledge
Saying the wrong thing	No eye contact	What is cultural capability?
Good intentions	Uncomfortable	Frequent flyers
Anxiety	Frustrated	Fear

Cultural safety (video 3)

For the third video, the words of the first videos will show through the curtain and black out to show just the cultural safety definition:

CULTURAL SAFETY is determined by Aboriginal and Torres Strait Islander individuals, families and communities. Culturally safe practise is the ongoing critical reflection of clinicians and systems knowledge, skills, attitudes, practising behaviours and power differentials in delivering safe, accessible and responsive healthcare free of racism (National Scheme’s Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020–2025).

The initial storyboarding for the first pilot was created after intense co-design sessions with Kirsty Leo and her colleague Jacinta Thompson. These meetings enabled their knowledge and vision for the video to be captured, as well as their ideas in relation to visual representation, animation effects, and camera movements. From these initial consultations, some animatics tests were developed by Thalia, PhD intern and project animator.

4 Defining a Visual Style

During these sessions, several visual style possibilities were brought to the table for testing, so the team could decide on a colour palette, image style, visual rhythm, animation effects, and potential camera angles and movement.

It was decided that the animations would be based on simple flat style 2-D graphics, with an emphasis on the typographic treatment of the words and thoughts expressed during the videos. As it is aimed at the clinicians, the animation had to maintain a certain corporate feel to it in order to create familiarity and remove the attention from some visual elements which exist as a vessel for the message [18].

A monochromatic palette was chosen to convey the hospital setting, using cold colours such as blue, blue-green and greys. Bright glares through windows and doors give the sense of light and depth, helping create right setting for portraying silhouetted characters. A clean and bold typeface is used throughout the video to optimise legibility, especially when setting up the “bias curtain”.

For the words to be legible on the curtains, it was decided that a simple and bold typeface should be used, but one that also carried some personality.

Hanley Pro was chosen for the words on the curtain, and Myriad Pro Bold was used for the subtitles in the final animation as it has a complete uppercase and lowercase set of characters.

5 Animation Resources, Camera Placement and Sound

In the final video characters are minimally animated with the dynamics of the scenes created through camera movement and typographic animation. This creates a feeling that the audience is navigating through a motionless scene where words are depicted and animated to demonstrate feelings and thoughts and moving the story forwards. The virtual, animated camera is oriented “in first person”. This subjective vantage point brings the audience straight into the story without the need for sophisticated animation or detailing of characters.

Animation resources similar to the ones used in Anime can be useful to represent thought and reflection. Static scenes, flat 2-D graphics, minimal animation, close-up of faces, removal of background details and change of colour to represent the switching between the real world and the world of the “mind” are all resources used in Anime style [18,19,21] that we chose to adapt to the Cultural Safety videos. Similarly, the use of type on screen to verbalise the ideas rather than using narration or dialogue gives the animation a more somber atmosphere which, at the same time, makes the videos social-media ready (where videos usually play without sound first).

Animating the typography so that it looks and behaves as part of the scenes gives the story a sense of truth and is more liable to capture the attention of the viewers. In these videos this was done by animating the text as the curtains, giving the thought quotes a bit of movement when shown with the characters.

The videos make use of hospital ambient sounds such as machine beeps and pulses, and the background rush of carts, beds and people. These hospital sounds are then taken over and silenced by biometric sounds from the human body such as heartbeat, breathing, and blood pumping sounds to depict anxiety.

Single words, simple real quotes, and official definitions of the concepts are depicted in the video. There is no dialogue between the characters. Quotes are used to represent thought and reflection.

6 Creating a Storyline

After a detailed briefing on cultural safety in hospital settings, the project team created storyboards and draft animations to capture the existing knowledge, vision, and ideas regarding visual representation, animation effects, and camera movements.

The original storyline consisted of three separate videos that respectively demonstrated concepts of cultural awareness, cultural sensitivity and cultural safety.

• Video 1: on Cultural Awareness, from the perspective of the clinician, showing the barriers that exist between them and FN patients. Barriers presented as words in a curtain between the clinician and the patient.

• Video 2: on Cultural Sensitivity, still from the perspective of the clinician, but from a reflective point of view, where the clinician reviews their own thoughts and biases in relation to caring for FN patients.

• Video 3: on Cultural Safety, this time from the perspective of the patient, showing the anxieties and feelings of being unsafe in the hospital environment and what cultural safety means.

The three videos could be played independently or together as a longer feature. Figure 1 shows the preliminary storyboards for the three videos.

Fig. 1

Storyboards for the three planned videos: animation (1) cultural awareness (top), animation (2) cultural sensitivity (middle), and animation (3) cultural safety (bottom). The three topics evolve as the clinician becomes aware of their own unconscious biases

At this point the team was excited to see the way in which the different disciplinary skills quickly intersected to bring together the initial concepts. The next step was to create a preliminary prototype to show to clinicians during a co-design workshop. The aim of the workshop was to give opportunity to clinicians to help the team refine elements of the video such as the storyline and the clinician’s character, and to test the overall idea of the video to assist reception with the target audiences.

7 Connecting with Users

The Design Lab team worked on the intention of creating a workshop that offered an authentic co-design process with as many opportunities as possible for true collaboration. The main concern of the team at this stage was to keep a balance between being honest and accurate to FN patients’ cultural safety issues and needs and Kirsty’s vision and aims. The challenge was to balance these objectives without offending the well-intended and highly trained clinicians who are not always conscious of their biases.

In order to achieve these outcomes, the team had to design a workshop that would stimulate open conversations around a prototype that was close enough to the envisioned outcome—but not too finalised, so that clinician participants could understand the concept and engage with the vision. At the same time, clinicians had to feel free to make changes and experiment with a high-fidelity prototype that was still malleable enough to be changed.

A co-design workshop was envisioned to test preliminary concepts with a reference group of clinicians invited by the QLD Health members. The intention of the workshop was to collect feedback on the video storyline and visual references. The original plan was to have participants collectively critique and apply interventions to the proposed video storyline and visuals. After the workshop, the team would incorporate the proposed changes and create the first iteration of the video for the Metro North team. This version would then be refined until it reached the desired state/outcome. Involving clinician participants in the early stages of the video creation is critical to bringing in the voices and perceptions of the actual audience. It also helped test the designers and creators’ own biases and assumptions.

7.1 The Co-Design Workshop with Clinicians

Originally there were three activities planned for the workshop:

Activity 1 Mapping the journey

The aim was to map the journey of the clinicians and FN patients, including feelings, expectations, and anxieties. The team had prepared a storytelling kit for the users to represent clinicians and FN patients’ experiences.

Activity 2 Finding the gaps

With the journey maps and story scenes at hand, the second activity involved watching the prototype animation and discussing how it represented the journeys mapped in the first activity and what changes could be made. Participants would be given empty story-boarding sheets where they could draw or describe their own plots and suggestions for the presented storylines.

Activity 3 Visualising the experience

Finally, during the third activity, participants were invited to comment on the current visual style and language, and were welcomed to suggest/design new potential visual concepts for the videos.

Due to Covid-19, the workshop which was planned to be presented in person had to be delivered fully online. This had a strong impact on the involvement of the participants and engagement with the prototype.

Even though the team was prepared to run an online collaborative workshop if needed (in 2021, the pandemic situation was still very critical), a series of technical issues related to access to online tools by both the team and the participants prevented some crucial activities from being held as planned. The negative effect on the perception of the prototype by the participants was significant, and in a way helped the team evaluate more carefully the impacts of the messages.

The workshop involved a small number of participants which was not, by any means, representative of the whole of the clinician population in QLD—it has been evidenced that design projects that involve some level of collaboration tend to offer better and more appropriate responses to the clients and audiences despite the number of people involved in the process [22]. In the end, despite veering from the original path, the issues with perception and participation did not invalidate the findings obtained from the workshop. In fact, the insights from the interaction with the clinicians revealed some weaknesses and strengths in the project that would otherwise may not have surfaced. The insights gained from the workshop with clinicians helped the team re-evaluate and reshape the project, as described below.

8 Findings from the Workshop

One of the major impacts of the technical issues is that it prevented participants from undertaking the storyline critique activity, where they would go through each storyboard, share their thoughts and have a chance to intervene on how the story could be told. For example, the text video would only be shown at the end, as a way to search feedback about the visual references and animation style. Apart from inviting participation, this process was planned to help participants become familiar with the story and its context.

Instead, the participants were shown the prototype video straight away, without being introduced to the concept or the complete story. The 15 second video test for the “bias curtain” became the only point for critique, with some participants mistakenly believing that the video was complete and that that was all that was going to be shown and produced.

The responses that the team got from the workshop were not entirely as expected, because the experience offered by the workshop was not the one planned. The responses, however, were still rich and valid, and revealed important issues and a few questions that needed to be considered before the videos were released:

• 1. The importance of contextualizing the argument

• 2. The fact that the words on the “bias curtain” and the way it is presented might feel “uncomfortable” and “finger-pointing” to some users

• 3. The need for visual accuracy and up-to-datedness in relation to how the treatment room, clinicians, and equipment looked like

Most importantly, the workshop revealed the need for an appropriate collaborative design process that takes into consideration some basic empathy and exotopy principles [23], as well as the fact that the process itself needs to be culturally sensitive by being prepared to embrace uncertainty [16], multiple epistemes (ways of thinking and doing) [24, 25], and expectations.

Most importantly, the workshop demonstrated that such profound transformational processes—such as designing tools for revealing unconscious bias— need more time to be delivered and digested before any kind of results can be identified.

It also showed that the proposed animation, with its use of visuals and sounds alone, had quite a strong impact on audiences (some workshop participants expressed surprise, others were a bit taken aback and offended by the video), proving design/animation to be an effective tool for the unique challenges and complexity of the project that needed to be conveyed in a short time frame.

In summary, the feedback from the workshop helped the team see the flaws in our first rendering of the animation and course correct from that point, creating a video that has more impact, was less “in your face”, and achieves its aim with more elegance. The changes proposed were not about being less honest, but communicating with clarity the true issues arising from unconscious biases and structural racism, and how these are the root causes of FN patients feeling culturally unsafe.

9 Crafting the Experience

A decisive response to the feedback was settling on one video rather than three separate ones. A single animated film would be more effective by maintaining consistency and cohesiveness of the story. For this to happen, the storyline needed to be slightly modified and refined.

The two characters—clinician and First Nations patient—were retained. The arc of the clinician character is built on the possibility of them building up their cultural awareness and sensitivity to be able to help create a safe cultural environment for all patients. This was made more explicit in the video by adding subtitles that represent the evolution of the thoughts of the clinician. Text for these subtitles were based on direct quotes from actual clinicians, previously collected by Kirsty Leo prior to the engagement of the Design Lab team.

For the final video, the story unfolds in three parts, maintaining some of the plot of the original three-video plan:

• Part 1: focuses on cultural awareness from the perspective of the clinician, showing the barriers that exist between them and First Nations patients. Barriers were presented as words in a ‘bias curtain’ between the clinician and the patient.

• Part 2: focuses on cultural sensitivity, still from the perspective of the clinician, but from a reflective point of view, where the clinician reviews their thoughts and biases about caring for First Nations patients.

• Part 3: focuses on cultural safety, this time from the perspective of the patient, showing the anxieties and feelings of being unsafe in the hospital environment and what cultural safety means. The story concludes with the clinician and the patient sharing the definition of Cultural Safety.

Similar to the original storyline, in the first part of the video the clinician is confused and not quite sure about how to deal with the FN patient. The first scene is set in the clinician’s staff room, where they collect the information for the next patient they need to see, who turns out to be a FN patient. The staff room was added in response to feedback from the workshop and the need to better contextualise the story and to represent the day-in-the-life of the clinician in a way that is closer to their day-to-day routine. As a result of clinician feedback, some of the stresses and anxieties that they themselves go through during their day at the hospital feature in the narrative, showing how clinicians feel they are regularly behind on their schedule.

As the door to the FN patient’s room opens, the clinician is faced with the ‘bias curtain’, where there are words and expressions representing facts and perceptions related to cultural biases towards FN communities and patients (Fig. 2). As they see the curtain, they don’t face it straight away, instead they look aside, and as they do so, see their reflection on a mirror/glass on the wall. This moment marks the second part of the video, where the clinician goes through a process of self-reflection, by perceiving their own biases and what has generated it. They begin to understand that they can change the way they think, act, and perceive FN patients, to deliver improved care through a cultural safe environment. The viewer is taken through the clinicians’ thought process by means of subtitles, with deep zooming in to the eye area on the face of the clinician that draws on anime techniques to evoke reflection. These forms of animated storytelling also enable the transition from hospital environmental sounds to inner body sounds like heartbeats and heavy breathing to express stress and anxiety. As the clinician’s thoughts evolve and they realise their own unconscious biases and role in perpetuating structural racism, they understand that one way to change the system is to change their own perspective. Once this epiphany happens, they turn back to the patient and open the curtain that reveals a clear view of the patient, unencumbered by the prejudicial words that populated it.

Fig. 2

Bias Curtain

During the third and final part of the animated video the story shifts to the patient’s perspective. In the beginning of the video the FN patient can be seen out of focus, sitting on the bed behind the curtain. When the frame cuts to focus on the FN patient, their feeling of anxiety is made clear by the look in their eyes—anxiety for knowing they might be cared for by someone who does not completely understand them and their deeper needs, and will not likely make an effort to do so. They know the biases that some clinicians may carry. After the clinician opens the curtain and comes through to the patient with a different attitude, the curtain is still there, behind the clinician, as seen from the perspective of the FN patient. Slowly the text on the curtain changes from the bias words to the definition of Cultural Safety.

10 The Final Version /Presentation/Current Uses

When the final version of the video was presented in the May 2021 HEAL Symposium, the reception was very positive and encouraging, and the video was greeted as having potential as a useful teaching tool across QLD Health. Any reservations the team held as to its efficacy following the reactions of the co-design workshop with the clinicians was removed. The unanimously positive reception of the animated video shows that creative approaches that generate innovative interventions can be effective responses to complex social and health-related issues, such as communicating cultural safety and unconscious bias.

We were able to achieve the aim of this project to co-design a provocation video that can be used by QLD Health to generate further engagement with clinicians around the state in relation to cultural safety in hospitals. These engagement opportunities will help provide answers to the question: “How might we change the way we work in hospitals to provide a culturally safe environment for First Nations patients and guarantee proper access [5] to care?”

Since its launch, Kirsty Leo has been using the animated video for training, with overwhelming success:

I share this video all the time and the response is overwhelming - it is part of our orientation for the whole of MNH and I am about to start a new Cultural Safety training package with this video for Charlies where I now work (Leo, 2022, personal communication).

11 Reflections

During this project, our team went through an important collective learning process. The multidisciplinary nature of the team offered great opportunities to engage in areas that we were not particularly familiar with, and the co-design workshop allowed us to re-think and reposition some of our own sets of beliefs and biases.

One of the most evident realisations of the team was that, in a collaborative multi-disciplinary environment, we needed to re-learn how to utilise and expand our creative and technical skills to reach outside of our field and achieve the results and quality designed by the team and expected by the end-users. For example, our team’s animation specialists reached into the fields of typography and illustration in order to put together a believable typographic flow in the curtain, while the visual communication expert in the team had to familiarise and go deeper into animation language and styles, in order to articulate their vision of how the video could look.

Similarly, the team realised that sometimes what you have to say with your project is not what the users are expecting to hear, so the message needs to be re-shaped in a way that the users accept and take it in, without compromising its integrity, authenticity, and aims. By listening to the users and understanding the context and main purpose of the project, we learned how to nuance the message in a way that brings people in, rather than shutting them out, while still keeping with the vision.

In the end, the QUT Team alongside the QLD Health team and with input from potential users, was able to produce a short sharp visual demonstration of the challenges faced by Non-Indigenous clinicians in approaching Indigenous patients in a hospital ward by using images, script, and sound. This project demonstrates, once more, the power of interdisciplinarity and co-design on intervening in wicked problems. Despite the complexity of the issues raised by cultural safety in clinical environments, a collaborative interdisciplinary team, well versed in a variety of expert disciplines and skillsets, can be combined to respond to difficult social, cultural and medical challenges.

The story of this project starts with the need for transforming QLD hospitals into culturally safe environments. A team of academics joined forces with an Indigenous QLD Health nurse to reframe and tackle the issue. She identified a core problem in the form of unconscious bias, something one doesn’t know they have until they realise it. The main difficulty when dealing with this kind of user is that the bearer of the bias is well educated and well-intended, and most of the time doesn’t know they are doing something that makes others feel unsafe. Our tool in this case was animated storytelling, which enables the telling of stories that challenge audiences’ perceptions, improves understanding, and creates an emotional impact, in ways not always possible through live-action or text alone.

Complex cultural issues, especially those related to cultural safety and health, can be sensitive topics for all involved in the design process. As such, considering different perspectives of storytelling and how animation or other creative media can be used to effectively communicate those perspectives in different ways can be extremely valuable to raising the impact of design/animation in other fields. At the same time, recognising the power of the creative demonstration of a problem can complement its critical analysis. This works best if the participants (especially the design team) are able to practice exotopy—the ability to see themselves from the outside and evaluate their own impact in the dynamics of the design process [23].

12 Conclusion

Healthcare is transforming as it responds to the care economy. The opportunities to work in healthcare offer rewarding challenges and partnerships that thrive off some of the fundamentals of design practices such as collaboration and iterative design processes. Healthcare needs input from creatives and designers to meet the needs of twenty-first century well-being and living.

Transdisciplinary relationships are important to not only produce effective content but also for professional/personal growth through the investigation and consideration of different, unique perspectives within the many facets of healthcare. This project demonstrates how the skillsets and capabilities of the creative industry professionals are relevant, and increasingly essential, to solve complex problems in broad sectors beyond those associates with traditional “creativity” and “entertainment”.

The effectiveness of the video created through this project comes from its addressing of the two core premises of cultural safety: (i) the need for healthcare practitioners to reflect on their own standings in their relationship with the recipient of care, and (ii) the fact that only the recipients of care can determine their sense of safety. The video could only achieve that due to the intensive collaboration process through which it was designed.

The Animated Cultural Safety project demonstrates that through deep listening and the ability to transpose abstract concepts, animated storytelling combined with design knowledge and tools can supply beneficial solutions through effective communication of complex topics for the healthcare industry.

View the final video here: https://research.qut.edu.au/heal/projects/cultural-safety/