Hospitals caring for rural Aboriginal patients: holding response and denial
Judith Dwyer A C , Eileen Willis B and Janet Kelly AA Department of Health Care Management, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia. Email: janet.kelly@flinders.edu.au
B School of Health Sciences, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia. Email: Eileen.willis@flinders.edu.au
C Corresponding author. Email: Judith.dwyer@flinders.edu.au
Australian Health Review 38(5) 546-551 https://doi.org/10.1071/AH14060
Submitted: 28 March 2014 Accepted: 8 July 2014 Published: 7 August 2014
Journal Compilation © AHHA 2014
Abstract
Objective To investigate how policy requiring cultural respect and attention to health equity is implemented in the care of rural and remote Aboriginal people in city hospitals.
Methods Interviews with 26 staff in public hospitals in Adelaide, South Australia, were analysed (using a framework based on cultural competence) to identify their perceptions of the enabling strategies and systemic barriers against the implementation of official policy in the care of rural Aboriginal patients.
Results The major underlying barriers were lack of knowledge and skills among staff generally, and the persistent use of ‘business as usual’ approaches in their hospitals, despite the clear need for proactive responses to the complex care journeys these patients undertake. Staff reported a sense that while they are required to provide responsive care, care systems often fail to authorise or guide necessary action to enable equitable care.
Conclusions Staff caring for rural Aboriginal patients are required to respond to complex particular needs in the absence of effective authorisation. We suggest that systemic misinterpretation of the principle of equal treatment is an important barrier against the development of culturally competent organisations.
What is known about this topic? The care received by Aboriginal patients is less effective than it is for the population generally, and access to care is poorer. Those in rural and remote settings experience both severe access barriers and predictable complexity in their patient care journeys. This situation persists despite high-level policies that require tailored responses to the particular needs of Aboriginal people.
What does this paper add? Staff who care for these patients develop skills and modify care delivery to respond to their particular needs, but they do so in the absence of systematic policies, procedures and programs that would ‘build in’ or authorise the required responsiveness.
What are the implications for practitioners? Systematic attention, at hospital and clinical unit level, to operationalising high policy goals is needed. The framework of cultural competence offers relevant guidance for efforts (at system, organisation and care delivery levels) to improve care, but requires organisations to address misinterpretation of the principle of equal treatment.
References
[1] Council of Australian Governments (COAG). National partnership agreement on closing the gap in Indigenous health outcomes. Canberra: COAG; 2008.[2] Anderson I, Clarke A, Renhard R, Otim M, Andrews S. Linking acute care to a strategy for improving Aboriginal health. Aust Health Rev 2002; 25 118–29.
| Linking acute care to a strategy for improving Aboriginal health.Crossref | GoogleScholarGoogle Scholar | 12474507PubMed |
[3] National Aboriginal and Torres Strait Islander Health Council (NATSIHC). National strategic framework for Aboriginal and Torres Strait Islander health: framework for action by governments. Canberra: NATSIHC; 2003.
[4] Department of Health and Ageing. National Aboriginal and Torres Strait Islander health plan 2013–2023. Canberra: Commonwealth of Australia; 2013. Available at: http://www.health.gov.au/internet/main/publishing.nsf/content/B92E980680486C3BCA257BF0001BAF01/$File/health-plan.pdf [verified 11 July 2014].
[5] Department of Health and Ageing. The state of our hospitals June 2009 report. Canberra: Australian Government; 2009.
[6] Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander people: an overview. Canberra: Australian Government; 2011.
[7] National Health and Medical Research Council (NHMRC). Strengthening cardiac rehabilitation and secondary prevention for Aboriginal and Torres Strait Islander peoples. Canberra: NHMRC; 2005. Available at: www.nhmrc.gov.au/publications/synopses/_files/ind1.pdf [verified 2 September 2011].
[8] Cass A, Devitt J, Preece C, Cunningham J, Anderson K, Snelling P, Eris J, Ayanian J. Barriers to access by Indigenous Australians to kidney transplantation: the IMPAKT study. Nephrology (Carlton) 2004; 9 S144–6.
| Barriers to access by Indigenous Australians to kidney transplantation: the IMPAKT study.Crossref | GoogleScholarGoogle Scholar | 15601407PubMed |
[9] Lawrence M, Dodd Z, Mohor S, Dunn S, de Crespigny C, Power C, Mackean L. Improving the patient journey. Darwin: Cooperative Research Centre for Aboriginal Health; 2009.
[10] Heart Foundation of Australia and Australian Healthcare and Hospitals Association. Better hospital care for Aboriginal and Torres Strait Islander people experiencing heart attack. Canberra: National Heart Foundation of Australia and Australian Healthcare and Hospitals Association; 2010.
[11] Purdie N, Dudgeon P, Walker R. Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. Canberra: Department of Health and Ageing; 2010.
[12] Eckermann A-K, Dowd T, Chong E, Nixon L, Gray R, Johnson S. Binan Gonnj: bridging cultures in Aboriginal health. Marrickville, NSW: Elsevier Churchill Livingstone; 2006.
[13] Alford K. Comparing Australian with Canadian and New Zealand primary care health systems in relation to indigenous populations: literature review and analysis. Melbourne: Onemda VicHealth Koori Health Unit, The University of Melbourne; 2005.
[14] Rogers GD, Barton C, Pekarsky B, Lawless A, Oddy J, Hepworth R, Beilby J. Caring for a marginalised community: the costs of engaging with culture and complexity. Med J Aust 2005; 183 S59–63.
| 16296954PubMed |
[15] Taylor K, Guerin P. Health care and Indigenous Australians: cultural safety in practice. Melbourne: Palgrave Macmillan; 2010.
[16] Cass A, Lowell A, Christie M, Snelling P, Flack M, Marrngnanjin B, Brown I. Sharing true stories: improving communication between Aboriginal patients and healthcare workers. Med J Aust 2002; 176 466–70.
| 12065009PubMed |
[17] Dwyer J, Kelly J, Willis E, Glover J, Mackean T, Pekarsky B, Battersby M. Managing two worlds together: city hospital care for country Aboriginal patients. Project report. Melbourne: Lowitja Institute; 2011. Available at: http://flinders.edu.au/medicine/sites/health-care-management/research/mtwt/ [verified 11 July 2014].
[18] SA Health. SA Health Aboriginal health policy. Ref. No. ASD/00917. Adelaide: SA Health; 2007.
[19] Australian Health Ministers’ Advisory Council (Standing Committee on Aboriginal and Torres Strait Islander Health Working Party) (AHMAC). Cultural respect framework for Aboriginal and Torres Strait Islander health 2004–2009. Adelaide: Department of Health; 2004.
[20] Fisher DA, Weeramanthri TS. Hospital care for Aboriginals and Torres Strait Islanders: appropriateness and decision making. Med J Aust 2002; 176 49–50.
| 11936281PubMed |
[21] Baker J. Theorising survival. Brisbane: Post Pressed; 2012.
[22] Durey A, Thompson SC. Reducing the health disparities of Indigenous Australians: time to change focus. BMC Health Serv Res 2012; 12 151
| Reducing the health disparities of Indigenous Australians: time to change focus.Crossref | GoogleScholarGoogle Scholar | 22682494PubMed |
[23] Henry BR, Houston S, Mooney G. Institutional racism in Australian healthcare: a plea for decency. Med J Aust 2004; 180 517–20.
| 15139829PubMed |
[24] Paradies Y, Harris R, Anderson I. The impact of racism on Indigenous health in Australia and Aotearoa: towards a research agenda. Discussion Paper Series No. 4. Darwin: Cooperative Research Centre for Aboriginal Health; 2008. Available at: https://www.lowitja.org.au/sites/default/files/docs/Racism-Report.pdf [verified 11 July 2014].
[25] Cross TL, Bazron BJ, Dennis KW, Isaacs MR. Towards a culturally competent system of care: a monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: Georgetown University; 1989.
[26] National Health and Medical Research Council (NHMRC). Cultural competency in health: a guide for policy, partnerships and participation. Canberra: NHMRC; 2006. Available at: https://www.nhmrc.gov.au/guidelines/publications/hp19-hp26 [verified 11 July 2014].
[27] Ramsden IM. Cultural safety and nursing education in Aotearoa and Te Waipounamu. Unpublished PhD thesis, Victoria University, Wellington; 2002.
[28] Dwyer J, Kelly J, Willis E, Mackean T, Battersby M, Pekarsky B, Glover J. Managing two worlds together: city hospital care for country Aboriginal patients. Study 2: staff perspectives on care for country Aboriginal patients. Melbourne: Lowitja Institute; 2011. Available at: http://flinders.edu.au/medicine/sites/health-care-management/research/mtwt/ [verified 11 July 2014].
[29] Kelly J, Dwyer J, Willis E, Mackean T, O’Donnell K, Battersby M, Pekarsky B. Managing two worlds together: city hospital care for country Aboriginal patients. Study 3: the experiences of patients and their carers. Melbourne: Lowitja Institute; 2011. Available at: http://flinders.edu.au/medicine/sites/health-care-management/research/mtwt/ [verified 11 July 2014].
[30] Kelly J, Pekarsky B, Dwyer J, Mackean T, Willis E, Glover J, Battersby M. Managing two worlds together: city hospital care for country Aboriginal patients. Study 4: complex Aboriginal patient journeys. Melbourne: Lowitja Institute; 2011. Available at: http://flinders.edu.au/medicine/sites/health-care-management/research/mtwt/ [verified 11 July 2014].
[31] Kelly J, Dwyer J, Willis E, Pekarsky B. Travelling to the city for hospital care: access factors in country Aboriginal patient journeys. Aust J Rural Health 2013; 3 109–13.
| Travelling to the city for hospital care: access factors in country Aboriginal patient journeys.Crossref | GoogleScholarGoogle Scholar |
[32] Kumaş-Tan Z, Beagan B, Loppie C, MacLeod A, Frank B.. Measures of cultural competence: examining hidden assumptions. Acad Med 2007; 82 548–57.
| 17525538PubMed |
[33] Lie DA, Lee-Rey E, Gomez A, Bereknyei S, Braddock CH. Does cultural competency training of health professionals improve patient outcomes? A system review and proposed algorithm for future research. J Gen Intern Med 2011; 26 317–25.
| Does cultural competency training of health professionals improve patient outcomes? A system review and proposed algorithm for future research.Crossref | GoogleScholarGoogle Scholar | 20953728PubMed |
[34] Potter C, Brough R. Systemic capacity building: a hierarchy of needs. Health Policy Plan 2004; 19 336–45.
| Systemic capacity building: a hierarchy of needs.Crossref | GoogleScholarGoogle Scholar | 15310668PubMed |
[35] Australian Institute of Health and Welfare. Rural, regional and remote health. Indicators of health system performance. Catalogue no. PHE 103. Canberra: Australian Government; 2008. Available at: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442459852 [verified 11 July 2014].
[36] Culyer AJ, Wagstaff A. Equity and equality in health and health care. J Health Econ 1993; 12 431–57.
| Equity and equality in health and health care.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2c7kvFCqug%3D%3D&md5=d10de46e7bb19b00f7f59b074c15ce35CAS | 10131755PubMed |
[37] Howse G. Legally invisible: how Australian laws impede stewardship and governance for Aboriginal and Torres Strait Islander health. Melbourne: The Lowitja Institute; 2011.
[38] Tynan M, Smullen F, Atkinson P, Stephens K. Aboriginal cultural competence for health services in regional Victoria: lessons for implementation. Aust N Z J Public Health 2013; 37 392–3.
| Aboriginal cultural competence for health services in regional Victoria: lessons for implementation.Crossref | GoogleScholarGoogle Scholar | 23895487PubMed |
[39] Willis J, Wilson G, Renhard R, Chong A, Clarke A. Improving the culture of hospitals project: final report. Melbourne: Australian Institute for Primary Care; 2010.
