Indigenous health workforce : Exploring how roles impact experiences in higher education

Associate Professor Naomi Sunderland is a member of the School of Human Services and Social Work and Co-Convenor of the Music and Communities research area at the Queensland Conservatorium Research Centre, Griffith University. She has an extensive research and publishing record in participatory, creative, place-based and community-based research in the areas of arts-health, wellbeing, and arts-based community development.

To improve the health of Indigenous people in Australia, it is critical to increase the proportional representation of this group within the health workforce (Aboriginal and Torres Strait Islander Health Workforce Working Group, 2017;Department of Health and Ageing, 2008). The health system is primarily staffed by non-Indigenous people, and this can replicate experiences such as lack of cultural safety and institutional racism (Best, , 2017Eckermann, Dowd, Nixon, Gray, & Chong, 2010;Ramsden, 1993Ramsden, , 2002. To increase the number and participation of Indigenous health professionals, the continuing development of strategies for retention and completion of Indigenous health students at universities are important aspects of the process. Before the arrival of the British to set up a penal colony, the roles of Aboriginal and Torres Strait Islander people were developed over many generations and were entwined with their cultural identity and specific expectations due to protocols and world view (Corporal, 2017;Holt, 2014;Nugent, 2015). Many of these roles would have included Indigenous people in health and leadership, such as traditional healers who provided for the healthcare needs of their cultural groups (Corporal, 2017;Holt, 2014;Nugent, 2015). However, many of the traditional roles that Aboriginal and Torres Strait Islander peoples have provided within their communities were changed through colonisation.
These colonisation factors of dispossession, separation, isolation and assimilation have further contributed significantly to the poor health status and life expectancy of Aboriginal and Torres Strait Islander people (Corporal, 2017;Lovett, 2014;National Aboriginal Community Controlled Health Organisation [NACCHO], 2018). In addition, Indigenous peoples were often steered towards the Eurocentric education system, which only allowed them to complete Grade 4, meaning that the only employment positions available were subservient roles such as maid, cleaner, labourer or yardman (Hegarty, 1999;Holt, 2001Holt, , 2014Huggins & Huggins, 1994;Moreton-Robinson, 2015;Rosser, 1978Rosser, , 1985Kidd, 1997Kidd, , 2006. Any roles outside of low-skilled occupations were deemed suitable only for non-Indigenous people. During the 1970s and 1980s, Indigenous health and the participation of Indigenous Australians in the health workforce in Australia became a national priority. Major initiatives, such as the National Aboriginal Health Strategy (NAHS) Report, emerged during this time. Nursing was one of the first health disciplines to address this priority of increasing the number of Indigenous students in the health workforce, led by people such as Sally Goold at Queensland University of Technology in the early 1990s (Goold, 1995) and Odette Best at University of Southern Queensland in the 2000s in Queensland alone. Therefore, by the 2000s, Australia had moved toward a national priority to train existing Aboriginal and Torres Strait Islander health workers in terms of formal qualifications and to attract more Indigenous young people into the health workforce. Some researchers (e.g. Altman & Hunter, 1997;Hunter & Daly, 2018) have argued that the education and employment opportunities that Aboriginal and Torres Strait Islander people have within Australia are still at the lower end of skills and education levels due to the various advantages non-Indigenous peoples have accumulated over the years since colonisation, due to (white) privilege and institutional racism (Larkin, 2014;Paradies, 2007). This has resulted in Aboriginal and Torres Strait Islander people being seen as having a mainly higher level of interactional (informal) roles within their communities yet having no structured higher level (formal) roles within the wider society (Lahn, 2018;Larkin, 2014).
Other research has highlighted obstacles that particularly affect Indigenous students studying at university; for example, institutionalised and interpersonal racism, stereotyping and negative expectations of Indigenous students' abilities, disconnection from family and kinship support systems, lack of acknowledgment and reflection of Indigenous knowledges in curricula, blurred boundaries in expertise between non-Indigenous lecturers and students when discussing Indigenous cultural knowledge, low socio-economic status, and family responsibilities (Bodkin-Andrews & Carson, 2016;Moreton-Robinson, Anderson, Blue, Nguyen, & Pham, 2020;Toombs & Gorman, 2010;West, Usher, & Foster, 2010). All of these factors can have an impact on students' overall wellbeing and success at university. Hence, in the higher education sector, strategies have often focused on retaining Indigenous students at university. The health and education sectors have been encouraged to work together to address the Indigenous health workforce through collaboration rather than leaving this onerous task to Indigenous units within universities. This was proposed to the National Aboriginal and Torres Strait Islander Health Council (NATSIHC) in 2004 by the Department of Education, Skills and Training (DEST), which noted that "care must be taken not to teach from a cultural deficit model, where it is often presumed that Aboriginal and Torres Strait Islander students and their worldviews are lacking" (p. 9). Instead, cultural understanding models, where teaching for Aboriginal and Torres Strait Islander students is the norm, should be encouraged (NATSIHC, 2008).
In 2008, the National Indigenous Health Equality Council (NIHEC) was established and highlighted the "National Training Plan for Aboriginal and Torres Strait Islander doctors, nurses, allied health workers, dentist, AHWs; recruitment and retention, training programs for non-Indigenous health workforce; National Network of Health Centres of Excellence for services, teaching and research" (Human Rights and Equal Opportunity Commission, 2008, p. 21). One area that required improvement was increasing the Indigenous health workforce (Indigenous Higher Education Advisory Council [IHEAC], 2011); specifically, the number of Indigenous health professionals to work for and provide cultural safety for Indigenous people Eckermann et al., 2010;Wilson, Kelly, Magarey, Jones, & Mackean, 2016). One discipline that has made gains in cultural safety is the discipline of nursing. West, Usher, and Foster (2010) argued that "Aboriginal and Torres Strait Islander nurses have played a crucial role when it comes to role modelling culturally suitable care for non-Indigenous nurses working with Indigenous patients" (p. 128). While there have been many successful programs in disciplines such as nursing to increase the numbers of health professional students, as presented by  and Goold (1995), the increase remains a challenge in all disciplines.
While Indigenous student enrolment within the health sector has nearly doubled since 2008 (Coates, Trudgett, & Page, 2020), the retention and completions of Indigenous students remain an issue (Universities Australia, 2017. Various researchers (e.g. Nakata, Nakata, Day, & Peachey, 2019;Page, Trudgett, & Sullivan, 2017;Toombs & Gorman, 2010) have found that Indigenous students are more likely to contend with additional obstacles such as racism, lower expectations and family responsibilities when compared to their non-Indigenous peers. These researchers argue that without understanding and support from university staff, Indigenous students have to overcome these difficulties alone. Given this, the significance of academic staff is paramount in shaping the experience and success of Aboriginal and Torres Strait Islander students (Bond et al., 2019;Doyle et al., 2020; Medical Deans Australia and New Zealand and the Australian Indigenous Doctors Association [MDANZ & AIDA], 2012;Smith & Robertson, 2020). Yet, universities are still largely dominated by non-Indigenous academics, many of whom are unfamiliar with Indigenous issues, communities or protocols (Holt, in press;Moreton-Robinson, 2004). Within health education, various frameworks (Department of Health, 2014; Universities Australia, 2020) have been developed to ensure that curricula is culturally safe; however, the success of such curricula may be limited if delivered by academics who are unfamiliar or unaware of the unique challenges faced by Indigenous students.
The aforementioned literature highlights that creating a strong Aboriginal and Torres Strait Islander health workforce is integral to providing healthcare for Aboriginal and Torres Strait Islander people, and it also illustrates the critical role of universities when it comes to educating a new generation of Aboriginal and Torres Strait Islander healthcare workers. Yet the literature also reveals that despite recent changes, the issues of retention and completion of Indigenous students within health education remain.
This research examines the roles of Indigenous students in the community, at university and in transition, to analyse whether this may be an obstacle that contributes to attrition and completion rates.

Conceptual framework
Roles are often related to one's identities. Roles determine the ways we interact with others in terms of behaviour and self-perceived or imposed social responsibilities. In a university environment, the roles that Aboriginal and Torres Strait Islander students play are usually regarded in much the same way as other students. However, a more nuanced look reveals the multiple roles that many Aboriginal and Torres Strait Islander students have in their lives. For example, many Aboriginal and Torres Strait Islander students are faced with the additional pressure of having to act as role models for other Aboriginal and Torres Strait Islander people in their families and communities while also potentially juggling between being parents and carers for their families. This may particularly be an issue in health professions such as nursing, which have higher rates of women who often take on the carer role within their families and communities (McGraw, 2018;Rose, 2014).
There may also exist tension between a student's existing role as a respected parent or Elder, in contrast to the role of a student positioned within the lower ranks of the (white) academic hierarchy (Home, 1997). Indigenous students may also be more inclined to experience negativity from family or community members who may regard the student's attempts to conform to the university's more "Westernised" norms as an affront to their Indigenous identity and, as a consequence, may label the student as "coconut" (brown on the outside and white on the inside; Carlson, 2016;Grant, 2017;Heiss, 2003). In contrast, some students may feel pressure to act as a role model for siblings or communities, and this may create tension if Indigenous students feel the need to pull away from their community and family responsibilities in order to meet their academic goals.
Various theorists (e.g. Goffman, 1959;Hardy & Conway, 1988) contend that changing or merging roles can cause significant stress and strain. Roles determine the ways we interact with others in terms of behaviour and self-perceived or imposed social responsibilities. Role theory (Biddle, 1979(Biddle, , 1986Blumer,1969;Goffman, 1959;Lemay, 1999;Mead, 1934;R. H. Turner, 2001) has emerged as a sociological perspective that theorises how people act at individual and collective levels within society and communities. There are five main perspectives on role theory: functional, symbolic interactionist, structural, organisational, and cognitive role theory (Biddle, 2003). In this study, role theory was used to explore what impact Indigenous students' "roles" had on their university experience. This theory was selected because the roles an Indigenous person has may change once at university. We focus specifically on two of the main perspectives of role theory: symbolic interactional and structural role theory. Structural or functional roles are viewed as fixed positions in society with certain expectations and requirements that may be positively or negatively enforced by sanctions (Cornwell et al., 2016;J. H. Turner, 2017). For example, for an Indigenous student, a structural or functional role may be an "Elder in residence". Symbolic interactional roles are seen as the role a person has when interacting with other people, the environment, and place (Blumer, 1969;Hardy & Conway, 1988;Goffman, 1959;Mead, 1934). These roles are more informal and are often linked to social functions, such as the role of a mentor, nurturer, carer and role model (Hardy & Conway 1988), all of which are roles that many Indigenous students perform within both their families and their communities.
Further aspects of role theory that are related to structural and symbolic interaction is that of role stress and role strain. Role stress relates to tension, distress, poor performance and limited organisation involvement (Hardy & Conway 1988;Home, 1997), whereas role strain is when an individual struggles to meet their work obligations and perform at full capacity in more than one role (Hardy & Conway, 1988;McGraw, 2018). The combination of roles that many Aboriginal and Torres Strait Islander students undergo may lead to role strain and role stress (Hardy & Conway, 1988) and this may have a detrimental impact on their academic studies. We contend that academics who have a better understanding of the different roles that Aboriginal and Torres Strait Islander people have at university, in their families and in their communities may be able to accommodate and support their students' adjustment to university life and studies.

Methodology
This study was guided by Indigenous methodologies as a proper protocol of engagement with the Indigenous participants (Martin & Mirraboopa, 2003). This is important because Indigenous people have been left out, ignored, not heard or objectified throughout previous research (Denzin, Lincoln, & Smith, 2008). Indigenous people's voices and their culture were central to this research, and as Aboriginal and non-Indigenous researchers we wanted their voices to be heard. The cultural safety and cultural humility aspects of using Indigenous methodological protocols, combined with the overlapping of Western and Indigenous knowledges, provided a safe space for the non-Indigenous participants within the interviews (Morseu-Diop, 2010;Nakata, 2002;2007a;2007b;Porsanger, 2004).
We have considered Nakata's concept of "cultural interface" as a way of conceptualising our combined use of Indigenist and Western research methodologies. Nakata argues that rather than regarding Indigenous and non-Indigenous theories and methodologies as binary opposites, they could be seen as potentially overlapping and complementary in some areas (Martin, Nakata, Nakata, & Day 2017;Nakata, 2007a). While procedurally this study also makes use of non-Indigenous theories to conduct the research, Indigenous Research Methodology (IRM; Kirkness & Barnhardt, 1991;Rigney, 2001;Smith, 2013) provided the overarching framework to ensure interviews were carried out respectfully and in a manner that supports and privileges Indigenous knowledges and the voices of Indigenous students.

Participants and recruitment
This research was reviewed and approved by the university's Human Research Ethics Committee. All participants were provided with a written information pack and consent form. Data were collected from one multicampus urban university in Australia. Participants included 17 current Indigenous health students and 10 academic staff members. Criteria for selecting student participants included gender, age, discipline of study and year of study. A full summary of resulting participants is included in Appendix A. In the criterion relating to year of study we endeavoured to recruit students who could represent first and final year of study and withdrawn-from-study experiences. Students studied at four different campuses. Two campuses were inner suburban, one was outer urban, and one was a coastal-urban campus. Students were recruited via the Indigenous student support unit through face-to-face contact over several weeks, flyers, and written participant information and consent packs across all campuses of the university. The process followed Aboriginal protocols of introduction and seeking permission and invitation to enter spaces with the endorsement and welcome of the Elders and leaders of that place (Best, 2011;Martin & Mirraboopa, 2003;Morseu-Diop, 2010).
Academic staff who taught in first-year health courses were selected for the study. We recruited staff from across different schools within the Health Faculty to obtain representation across disciplines. Staff who taught into first-year courses and who would be interacting with first-year Indigenous students were selected to highlight the potential relationship between academics' knowledge and expectations of Indigenous people and the students' experiences of university study. Despite not deliberately recruiting for this, several of the participating academics taught across two or all years of study. Academics were also recruited following IRM protocols. We first approached heads of school and first-year coordinators in the Health Faculty to seek their approval and permission to invite staff in their school to participate. Staff were invited to participate via flyers and direct email.

Data collection
Qualitative, semistructured, in-depth interviews were conducted by the first author following IRM protocols such as building relationships, using proper protocols of introduction, being humble in the space, and giving and receiving feedback (Best, 2011;Martin & Mirraboopa, 2003;Morseu-Diop, 2010;Neuman, 2011). The interviews were conducted at locations where the Indigenous students and non-Indigenous staff felt culturally safe, such as university offices and the Indigenous unit offices. This was essential for quality data to be collected. Interview questions on roles were formed around this research question: How do Aboriginal and Torres Strait Islander health students change their roles from community to their roles in the university's Health Faculty courses? Open-ended interview questions were used to collect the data. This allowed flexibility for the interview to flow freely between the researcher and participants. The average length of the interviews was 27 minutes and 48 seconds. Some questions were the same for both students and staff, while others were different. All questions are listed in Appendix B.

Data analysis
We used inductive data-driven theming to conduct our analysis that was then combined with deductive theory-driven coding according to role theory (Brooks, Bee, & Rogers, 2018). After interviews were recorded and transcribed, Authors 1 and 2 used NVivo 12 software to analyse and code the data. Indigenous authors 1 and 2 then developed iterative themes and categories to distinguish the stage of study for students (e.g. first year, previously withdrawn or final year). Theming was not mutually exclusive: participants brought their unique story that did not sit neatly within a single theme. Thus, this data analysis was complex, requiring an Indigenous lens (authors 1 and 2) to appreciate the heterogeneity. Once the analysis was complete, Authors 3 and 4 conducted a further review to ensure participant responses accurately coincided with the themes applied. Areas of uncertainty or disagreement were reviewed by all authors and respectfully discussed until consensus was reached.

Findings
Findings are presented under the following headings: community roles, university roles, and transition between communities to university. We first discuss how Indigenous students saw those roles and then how academic staff saw Indigenous students in relation to roles.

Community roles
The roles that participating students performed in their community varied and were sometimes related to their role as a future health professional. For example, a first-year student spoke about their role in the community as being tied to their role as a student and future health professional: I guess the role I kind of play in that is kind of like I'm the … fellow that moved to the city and doing his med degree so it's like a sense of pride there, as well it makes me sort of feel good that my family feel proud of what I am doing as well. (Interviewee 013).
Connection to family and community is an ongoing role for this student as is his role of being away from community. It appears the student and his family see the role of being trained in medicine as part of a wider community role. The symbolic interactional role of this student is seen as a doctor in training even within his community and is seen as a source of pride as well as expectation. By contrast, a student who had previously withdrawn from studies posed: I work as a disability worker and a community support worker at an Aboriginal-run respite centre … through my work I wear my uniform as red, black and yellow, so I identify as that community support worker but as an Aboriginal community support worker, you know, as well. So, I don't think people [at university] have any doubt about where I stand. (Interviewee 027).
This indicates that there can be tensions as to which role is a priority. The student wears the Aboriginal colours to show he is proud of his role in the Aboriginal community and this may challenge others at university ("people have no doubt where I stand"). Students in this situation can experience differences in the way their structured community roles are respected and recognised in the university, and this can cause further tension. A final-year student remarked: I guess my role in the community based on just the work that I have chosen to do in the community is more of a helping and nurturing role … I have done a lot of work with [name of Indigenous community organisation] and I have done a lot of work for [name of Indigenous community health service], particularly helping young people and sort of just being there … I am that support person that, you know, the young ones know, a few of them know where they can get me even if I am not at work so they know where I am so they know they can come and see me when they need help. (Interviewee 004).
This statement reveals how the student has a symbolic interactional role as a mentor and support person within her community. However, her enrolment within the program suggests she is studying in an attempt to formalise that nursing role, suggesting that some Indigenous students go to university specifically to formalise existing informal roles, which while accepted within their community may not necessarily be accepted within an institution without further accreditation. However, further statements made by this student, such as "they know they can come and see me when they need help", indicates that she accepts the responsibilities of these dual roles within her life if it means bettering the health and wellbeing of her community.
These statements from the students demonstrate that while community can be a source of strength for Indigenous students navigating between two worlds, some may at times feel overwhelmed as they try to fulfill the needs of both. As such, students may be more inclined to withdraw if they feel the pressures stemming from their new role as students collide with those of their pre-established symbolic interactional or structured roles within their community.

University roles
First-year students spoke about still finding their way through their new role as student and as future health professional. As one first-year student remarked: I guess [I'm] somewhat of a role model … more so for my younger brother but also for his friends and some of the younger uni students … I try and stay a role model in the outside aspects of uni life. (Interviewee 010) The "outside aspects" of life mentioned by this participant refer to being a role model to other students at university on matters that often do not relate to the hierarchy of university studies. A student who had previously withdrawn from university studies reflected: Learner! … I got to really respect learning and love learning and that's exactly what I am here to do. I don't want to be the loudmouth … I am just here to learn … and why? To achieve my goals. I'm not here to nurture, I'm here to, look, I'm here to nurture to myself really because I need this, [not] only do I need this, I want this. (Interviewee 006).
The learner role can be seen as an interactional role or a structured role when they are a student at university. The students' comments may indicate that they are actively rejecting the role of role model or nurturer for community or family in favour of needing to look after their life at this time, which is also an important perspective to consider.
Final-year students who had been at university for at least two years indicated more familiarity with their future structured health professional roles. For example, one final year student remarked: In the university aspect I see myself as a person who is representing Aboriginal and Torres Strait Islanders in the fact that I'm first in the family and the fact that, you know, not everyone there is, and it is said to be a high dropout rate of Indigenous people in school and, [as] such, I see myself as pushing through as one of those Indigenous kids who wants to get somewhere and, you know, hopefully in the future will motivate others at high school when I'm a teacher myself to get somewhere. (Interviewee 012).
Hence, students indicated complex roles defined in relation to their family, specific home community and Aboriginal and Torres Strait Islander peoples in general. Roles at university were often defined in relation to Indigeneity and were primarily symbolic interactional-rather than structured-such as role modelling, learner, being nurtured, representing, getting somewhere, and motivating.

Transition between the community and university
Students spoke about diverse aspects of transitioning from community to university roles. That transition was particularly important in the first two years of study when students often struggle and may leave university. While many of the participants indicated that their roles were still in flux or under development, others indicated that they were trying to keep "both" roles, that is, in community and at university. Having more than one role can contribute to role strain for these Indigenous students, which can affect roles in both contexts; for example, one student said: So far, I haven't grasped the transition up, I got so much other crap going on in my life that I am still trying to figure that out, the transition has been smoother knowing that I've got that network here [at university] that I can come to for support. Here I'm trying to be more active.… That is a transition. That's where I'm headed, so that I can take here and take that back to the outside too. (Interviewee 008) Students further indicated that social networks developed within university transferred to "outside" contexts. Having support at university during the transition of roles was seen as important to help overcome role stress. One student spoke about finding her new role as a student and no longer being in "mum mode": I am a single mum, I'm at home. I'm always mum mode at home so when I do find myself when I come to university, I am no longer in that mum mode I'm in, I'm learning to be to find myself. (Interviewee 002) Such experiences were common for Indigenous people who are both parents and students. Looking after family is an important role in the Indigenous community and students have to balance this with the new student role (Home, 1997).
Some students indicated that they found their roles in community and university to be quite similar and hence found transition to be easier. For example: My roles are sort of similar, hey, in both sort of areas. I think that university transfer over from the community is that I guess it is very similar. (Interviewee 009) Many Indigenous people may be working in health or related areas already and want to upgrade their qualification and skills, so the roles appear similar, creating an easy transition to university.
One final-year student remarked that the transition to university can be challenging for Indigenous students who are forced to acclimatise to mainstream "white" institutions. In her words: I can imagine it's very hard for people who just leave their community who have grown into adolescence who [are] young adults in their community; up home I think it would be harder for them to transition that role and find their place within the university because it's so formal and it's so white that coming from an Aboriginal community to a very white English structured kind of place, it would be hard for you to find your role, you know; because I've been out of my community for a bit I know this is just an institution. (Interviewee 011) Students indicated that transition from community to university can be radical in nature, that is, to the extent that students feel that they are "changing worlds" and need to rapidly acclimatise to the white, mainstream institutional setting. Yet, students also indicated that when their roles were similar in community and university settings, that transition between worlds was simpler and easier.

Community and university roles
Overall, academics interviewed for this research displayed a lack of understanding of Indigenous community roles and the roles that Indigenous students enact at university. There was a strong theme of equality or "sameness" that persisted across academics with regard to Indigenous students; that is, impressions that Indigenous students are no different to any other [non-Indigenous] student, as revealed in the following three quotes: If an Aboriginal student enrols in a course, say medicine or nursing, I think they would need to fulfill the roles and expectations of the student, just like any other students there, and I would personally not think that the Aboriginal student himself or herself would want to be treated any differently simply because they are of Aboriginal heritage, and I think that they would want to blend in and do what everybody else does. They have the same aspirations, they sit the same exams, they are looking for the same student outcomes, same terms of employment, so I would not think that the role of an Aboriginal student in a university is any different from the other students. (Interviewee 025) I don't think that the roles of the Aboriginal and Torres Strait Islanders within their communities are any different than they are for anyone else in the broader community, or anyone from the broader community relating down to the Aboriginal and Torres Strait Islander communities and vice versa, because there are going to be leaders, there are going to be people who carry out the day-to-day tasks, there are going to be teachers. I like to think that everyone in every society acts as a teacher. Some people do it better than others, so I don't see there's any difference. (Interviewee 024) I see the [Indigenous student's] role within a community to be the same as the role that would occur in any community. (Interviewee 019) These participants' reflections suggest unfamiliarity with Indigenous communities and Indigenous culture; specifically, the structural or symbolic interaction roles that Indigenous students assume or are expected to assume within their communities.
While this academic also spoke about Indigenous students as having an "equal role" to non-Indigenous students, paradoxically they continued to point out differences existing between Indigenous and non-Indigenous students-first, with specific reference to special entry: I think that they have an equal role to other students in that equal opportunities, I think that, obviously, there's programs and special funding entries to acknowledge the importance of having Aboriginal and Torres Strait Islander students coming through the university. (Interviewee 022) And later, in reference to training (specific community-service training) and roles (the informal roles Indigenous students may play as mentors for both their communities and the university): To train up these individuals [Indigenous students] in professions that can then go on and actually service their communities with that health professional education, but as a respected member of the community, I think is probably the most ideal way to do it. So, I think they have got a key role in the university. I think that they have got a key role in educating staff and other students about their identity and possibly about shedding new light on each profession. (Interviewee 022) Another academic acknowledged having little insight or knowledge of Indigenous people's roles within their communities, yet their statements revealed strongly deficit perceptions of Indigenous communities: I'm in this health discipline and I don't have much experience with this community. All what you hear about is low socio-economic standards so, honestly, they're in health, like, it's pretty bad in these communities. (Interviewee 023) While this particular academic indicated a strong deficit perception of Indigenous communities, not all academics interviewed held that perspective. However, most of the academics interviewed (7) did tend to reveal a position that maintained Indigenous students and communities were no different to "any community" and therefore should be treated the same as any other students. This suggests that some academics may struggle with their perceptions of Indigenous students and the complexities of the varying roles they may hold. While some academics' statements revealed an acknowledgment of difference in relation to student entry requirements, training, and the information and cultural knowledge Indigenous students may hold, there was little indication that the academics held any nuanced understanding of the complexities of the symbolic or structural roles some Indigenous students may have within their communities or how this may influence their ability to obtain their desired structural roles as health professionals, community leader and educators.

Transition between community and university
The theme of sameness between Indigenous students and non-Indigenous students carried over to academics' discussion of transition between community and university. They indicated that they saw challenges for all students in transitioning to university but also additional challenges for Indigenous students; for example: Changing that role, yeah, absolutely, where their role in the community might have been a mother and partner and maybe a partner of in family or living in a community group and then they have to now find time to engage with, you know, full-time course load maybe. Yeah, it's a big role, a big transition.… I absolutely am aware that anybody who comes to university has a transition and school leavers just as much as mature age, but the mature age students and often Indigenous have other life responsibilities that have an impact and I am supportive of that … but I expect that they will remain in contact with me and then I can support them to achieve. (Interviewee 016) This academic acknowledged that the transition to university is difficult and perhaps more so for mature age and Indigenous students, depending upon their life circumstances and responsibilities. While the academic relayed that they would be willing to support students in difficult circumstances to achieve, there was still the expectation that it would be the student's responsibility to contact them to let them know that was an issue, as opposed to proposing any systemic change within the institution. With academics, the role transition for Indigenous students is seen as quite challenging because they must be an independent learner, which is different to other learning experiences. This may relate to school leavers or mature-age students studying in vocational education courses: There are some additional pressures for some Aboriginal and Torres Strait Islander students with some of that conflict of expectations, and I think for a student in general the transition to university can be quite challenging as well. They are expected to be more independent learners, the standard, the difference from school or other learning opportunities that they would have had, and so an Aboriginal Torres Strait Islander student had those same transitions as well in terms of learning what university's about and how to manage that when nobody's keeping that close an eye on you to say, "Are you doing your work?" (Interviewee 015) The previous interviewee implied that Indigenous students will struggle during the transition the same as other students who have had support in other educational environments outside of university. This suggests that the change of roles during this transition for Indigenous students will require them to reach out for assistance from academics and Indigenous student support units during the transition.

Discussion
According to Hardy and Conway (1988), roles play a key part in forming our identities. Gardiner (2000) stated that a key criterion for Aboriginal and Torres Strait Islander people is being accepted in your community as a member of that community. Connection to land, both historically and currently, is regarded as critical to Indigenous identity (Styres, 2017). This involves having a place or a role in the Aboriginal and Torres Strait Islander community where you are have lived or currently live. While some university students may have community roles, some may not.

Community
In relation to their community, Indigenous students spoke about seeing themselves as carers, educators, teachers, mums, learners and role models (Gardiner, 2000). This indicates that some Indigenous students have what may be described as symbolic interactional roles (Goffman, 1959). Those roles also indicate structural roles within Aboriginal and Torres Strait Islander communities. By contrast, the academics interviewed spoke about seeing the Indigenous students as being largely the same as other students in relation to their roles within communities. Responses indicated that some academics had a significant lack of understanding of Indigenous roles and difference. Other academics spoke about Indigenous students being leaders or future leaders in their communities primarily because they were studying, which further indicates a lack of understanding of Indigenous community and cultural roles that do not rely on qualifications from mainstream white institutions.

University
Indigenous students spoke about roles at university as being "helper", "educator", "learner" and "token", which could be seen as symbolic interactional roles, with the exception of the first-year student who indicated a structured role of "physician-in-training" (Carter & Fuller, 2015;Goffman 1959;Hardy & Conway 1988;Mead, 1934). Yet, when looking at these roles more carefully, one could interpret other roles listed as structured roles as associated with skills and knowledge for the degrees and professions that Indigenous students are studying. An example of this is an Indigenous student who saw their role as a "helper" by studying to be a social worker to support people within their community. What may be seen in one culture or community as a symbolic interaction could be seen as a structured or functional role in another community (Carter & Fuller, 2015;Goffman, 1959;Hardy & Conway, 1988).
The non-Indigenous academics interviewed regarded Indigenous students as having the same roles as other students at university. While this may sound encouraging, it suggests that some academics did not truly recognise the cultural background of their Indigenous students or the unique communities that they represent. Likewise, the academics indicated no awareness of cultural and community roles that Indigenous students reported as being distinct from "any other student". Nevertheless, saying that they have roles as "achievers" and "role models" could suggest they recognise the Indigenous students as representing Aboriginal and Torres Strait Islander people and communities. Yet some academics also relayed that Indigenous students have roles as "mentors" and "educators" for non-Indigenous students and even non-Indigenous staff. While this suggests that academics did recognise the Indigenous students as representing Aboriginal and Torres Strait Islander people and communities, they may also, intentionally or unintentionally, put Indigenous students in the role of "teacher" where they are inappropriately expected to mentor and educate other students on Indigenous issues, cultures, and knowledges, potentially at the detriment of their studies.

Transition
The students interviewed spoke about different aspects of their transition from community to university experience and acknowledged that their roles had shifted during this transition. Some students spoke about their role changing from their current role in the community to a more professional role, while other students acknowledged the role as similar and that they were simply enhancing the role they would continue back in their community. Other students spoke about dual roles within university and community and family. Roles were also influenced by transitioning from rural to urban, and from a cultural to a white institutional environment, as well as from an interactional role within community to a future structured role as a professional. Indigenous students saw their roles as needing to conform to the structured roles of Western society. Yet, they expressed a need to reclaim the structured roles that had been lost in their communities and that were often seen only as organic symbolic interactional roles due to the historical impacts of colonisation. The academics interviewed saw Indigenous students as not being ready for their role in university due to cultural background and structural disadvantage (i.e. deficit thinking). However, academics also saw the role of the student as being the "same as any other students" in that struggle to transition into university.

Summary
A preponderance of the academic participants emphasised equality rather than equity or the particular and unique roles of Indigenous students. They reaffirmed that Indigenous students must change their roles or take on a new role with help. They saw help as being facilitated by the student approaching the academic or using specialist services such as Indigenous student support units. This could be interpreted as Indigenous students moving from a perceived symbolicinteractionalist role in the community to a structural or functional role of student and future health professional in training (Hardy & Conway, 1988) and suggests that academics may have a view of Indigenous people as not having a structured role in society when coming from their community, unless that role was the same as the rest of mainstream society. Such perceptions may lead to Indigenous students feeling as if their role as a community Indigenous knowledge holders is not valued within the university setting, despite the potential of being asked to share their knowledge as a mentor for "all things Indigenous" for their non-Indigenous peers and academics. This adds an additional burden to many Indigenous students who may already be navigating new knowledge systems and roles. By disregarding the diversity of the roles within Indigenous communities or the complexities and responsibilities associated with those roles, non-Indigenous academics not only risk isolating Indigenous students, they also risk denying the many benefits all students would gain from having increased awareness and understanding of Indigenous knowledges, protocols, lore, governance, education and kinship systems.

Limitations
There were several limitations to the study. The research was limited to a sample size of 27 participants who represent only a small proportion of Indigenous students and academics in the health faculties in universities around Australia. It would have been of benefit to interview other administration staff at the university, including senior management, about their perceptions of Indigenous students' roles. It would also have been beneficial to interview Indigenous university staff about their perceptions of Indigenous students' roles. There was more reliance upon participant feedback as opposed to direct observation in the classroom.

Recommendations
The results of this study indicate that the following recommendations should be adopted: 1. Academics need to be aware of the roles that Aboriginal and Torres Strait Islander health professional students already perform in their communities and the roles that they are being trained for when they return to their communities. This goes beyond cultural awareness towards an appreciation and valuing that Indigenous systems operate alongside non-Indigenous health and education systems. This requires action from the universities and academics to facilitate these dual systems to operate smoothly. The aim of this action is towards providing cultural safety for the Indigenous health students.
2. There needs to be a clearer understanding of Aboriginal and Torres Strait Islander people leaving their communities to gain the qualifications to enhance the health of the whole community through regaining the structural and functional roles that are particular to Indigenous structures and processes. Often these roles have been eroded or lost due to the legacies of colonisation.
3. The students should not feel guilty about leaving their communities to study at university as they will regain the original structural and functional roles within their communities that may have been removed through colonisation. This can be achieved by having Indigenous units within the universities to support Indigenous people through these transitions and reassure them that they will regain these community roles.
4. Universities need to increase the Indigenous staff of Indigenous units and provide more professional development for all staff on cultural safety and responsiveness to be more accommodating for Indigenous students and communities.
5. There needs to be more Indigenous academics teaching into health disciplines, which has been ongoing in disciplines such as nursing (Best & Stuart, 2014).

Conclusion
Today, more Aboriginal and Torres Strait Islander people are entering higher education with a view to giving back to their immediate or wider Aboriginal and Torres Strait Islander communities. Upon entering university, some Indigenous students experience shifts in terms of how they see themselves and how their community sees them. There may also be a transition period as both the individual and the community learn to adapt to the individual's new or emerging role. Unfortunately, this transition does not always run smoothly. This is highlighted by the high percentage of Indigenous students' attrition rates within higher education, including health degrees, where Aboriginal and Torres Strait Islander students have left the university program prior to obtaining their desired roles as health professionals.
This study found that Indigenous student roles in communities and university were largely invisible or seen as symbolic interactional roles rather than structured roles. If students have a structured role in their community, this needs to be made clear so that both the student and the academics have knowledge and appreciation of the responsibilities that student already has within their community. Student and future health professional roles may consolidate and positively extend Indigenous students' existing community roles. Yet, expectations of being a future leader or role model can cause additional role strain to Indigenous students. Campus 1 (n = 16) Campus 2 (n = 10) Campus 3 (n = 1)