Experiences of occupational therapy students undertaking an Aboriginal and Torres Strait Islander health module: embedding cultural responsiveness in professional curricula

Introduction

A culturally safe and competent allied health workforce is essential.^1,2 Health professional university students need to be able to work with Aboriginal and Torres Strait Islander peoples safely and respectfully to break down the effects of colonialism and colonisation³ and to facilitate positive interactions with Aboriginal and Torres Strait Islander clients. The occupational therapy profession has prioritised cultural safety through accreditation standards that recognise competencies in understanding Aboriginal and Torres Strait Islander peoples’ experiences of health, wellbeing and occupations and the need to respond appropriately using culturally responsive practice strategies and respectful communication.⁴

Cultural responsiveness includes being able to identify and challenge personal cultural assumptions, values and beliefs, and to recognise and respect different cultural views of the world.⁵ This promotes an understanding of the influences of culture, racism, histories of oppression and other contextual factors⁶ on Aboriginal and Torres Strait Islander peoples’ health. Indigenous Allied Health Australia’s cultural responsiveness framework⁵ defines cultural responsiveness as the way in which health professionals deliver and maintain culturally safe and effective practice, such as focussing on health assets and strengths, using culturally appropriate assessment approaches⁷ and working together to ensure that intervention is culturally relevant.⁸ Cultural responsiveness goes beyond cultural safety and cultural competence by describing the actions that are practised to create and maintain a culturally safe service. Adult learning principles are recommended,⁹ as well as facilitating critical and reflexive learning experiences while ensuring the wellbeing of students.

A scoping review of health professional Aboriginal and Torres Strait Islander curricula¹⁰ described compulsory units, modules or full-day workshops. Content included historical, political and social aspects of Aboriginal and Torres Strait Islander peoples’ health, social determinants, cultural safety, racism, equity, cultural health beliefs and issues relevant to specific professional practice. Assessment items included group activities, online quizzes and reflective activities.¹⁰ The current study evaluated a module delivered to occupational therapy students at the University of Sydney by Aboriginal and Torres Strait Islander academic staff and non-Aboriginal occupational therapy academic staff. The unit consisted of 3 h contact per week over 4 weeks. Students worked in groups for the first hour with a case study for their group each week (rural or urban), which developed over the 4 weeks with extra information added each week. Several case studies were used across the groups. They also participated in 2 h workshops led by Aboriginal and Torres Strait Islander university staff on communication and kinship. The workshops informed the case study activities but were not directly linked. Guest speakers included Aboriginal and Torres Strait Islander service providers. Individual assessment tasks included a self-directed module of reflective tasks (pass/fail), and the final assessment task was the development of an occupational therapy position statement on Aboriginal and Torres Strait Islander peoples’ health (Fig. 1). A pre-module survey encouraged students to reflect on their prior understanding of Aboriginal and Torres Strait Islander peoples’ culture and health and to consider any gaps in their knowledge (Supplementary material file S1).

Fig. 1.

Outline of the Aboriginal and Torres Strait Islander module content. OT, occupational therapy.

Although the principles of presenting curricula and learning opportunities about Aboriginal and Torres Strait Islander peoples’ health and culture are known,¹¹ there is little data about how occupational therapy students respond to such learning activities. This paper will describe the findings from interviews with undergraduate and Master’s entry occupational therapy students about their participation in a specialised module on Aboriginal and Torres Strait Islander health and practice (Fig. 1). This study aimed to explore the reflections of occupational therapy students about their learning experiences and any extended understanding of Aboriginal and Torres Strait Islander peoples’ health issues and approaches during the module.

Methods

This study used a qualitative descriptive design.^12,13 Ethics approval was gained from The University of Sydney Research Ethics Committee (ref: 2013/212). One author was an Aboriginal and Torres Strait Islander person at professorial level, and the other two authors were non-Aboriginal occupational therapy academics with clinical experience in practice with Aboriginal and Torres Strait Islander communities. All authors were involved in the development and presentation of the module, and the conception and implementation of the study. Invitations for students to participate were made by an academic who was not involved in the teaching of the module.

Undergraduate (n = 55) and Master’s entry (n = 52) students who undertook the Aboriginal and Torres Strait Islander health module in 2016 (n = 107) were invited to participate in interviews. In-depth, semi-structured, face-to-face interviews were conducted. A broad interview guide was developed consisting of open-ended questions to focus on the student experience (Supplementary material file S2). Interviews were conducted by LM and were digitally recorded with permission and then transcribed and de-identified prior to analysis. Interviews lasted between 10 min and 30 min. Topics explored included student understandings of Aboriginal and Torres Strait Islander peoples’ health and culture, feelings about undertaking the module (individual and group components), and how the module contributed to learning, preparation for placement experiences and future practice.

The interview transcripts were analysed thematically.¹⁴ Each transcript was analysed by assigning codes on a line-by-line basis, grouping codes into categories and developing overall themes. Field notes were taken by LM before and after each interview to reflect on any feelings and thoughts or emerging themes in relation to the interviews. JGil contributed an Aboriginal voice to the findings and compared the findings to those of other professional groups across the University of Sydney. Data saturation was reflected in repeated reference to similar issues from the dataset. Pseudonyms were used to preserve anonymity, and direct quotes illustrated the relevant themes.

Results

A total of 18 students (n = 3 undergraduate and n = 15 Master’s) aged 21–42 years were interviewed (response rate, 16.8%). None identified as Aboriginal and Torres Strait Islander persons, two were international students and two were male. Three themes were identified: (1) student contexts of approaching the Aboriginal and Torres Strait Islander module, (2) experiencing the module with other students, and (3) student learning gains following the module. These themes and supporting quotes are summarised in Table 1.

Discussion

This study sought to explore the perceptions and experiences of occupational therapy students at the University of Sydney about their learning experiences during a module on Aboriginal and Torres Strait Islander health and culture. Findings reflected how one group of occupational therapy students grew in their knowledge and understanding of Aboriginal and Torres Strait Islander peoples’ health and culture from a position of relative ignorance, and how the module contributed to improving confidence and self-awareness. We could not compare our findings with other occupational therapy programs because there are few published examples of Australian university-based learning activities about Aboriginal and Torres Strait Islander peoples’ health and culture. One international review of health professional students undertaking Indigenous curricula included nine Australian studies, but none included occupational therapy students.¹¹ This module does, however, align with an educational program developed by Dentistry at the University of Sydney.¹⁵

For many participants the module was their first exposure to the injustices experienced by Aboriginal and Torres Strait Islander peoples, and many had very little contact with any Aboriginal and Torres Strait Islander peoples. However, contact with Aboriginal and Torres Strait Islander peoples does not always translate to understanding and positive attitudes by non-Aboriginal people.⁹ Few students had professional placements that included Aboriginal and Torres Strait Islander peoples, therefore students were unable to learn in the context of occupational therapy service provision. Other studies have also found limited knowledge about Aboriginal and Torres Strait Islander peoples’ health issues prior to undertaking an education activity,^16,17 and students suggested that their main source of prior knowledge came from the media or prior schooling,¹⁸ which may be a barrier to student learning.

A single educational module focused on Aboriginal and Torres Strait Islander peoples’ health and culture is unlikely to result in substantial outcomes for non-Aboriginal students. For instance, the degree of immersion and Aboriginal and Torres Strait Islander ways of learning (such as story sharing, narrative-driven learning, land-based learning and connection to community)¹⁹ in the module were limited by program requirements, resources and time. It has been suggested that educational programs might lead to short-term improvements to professional practice, but few have demonstrated long-term change.²⁰ Curricula need to be responsive and focused on supporting students on their continuing journey in their evolving understanding over time. Given that the proportion of Aboriginal and Torres Strait Islander occupational therapists and occupational therapy students remains low, there is a lack of opportunity for ongoing meaningful exchanges of understanding through informal networks and professional modelling.

The Australian Health Practitioner Regulation Agency has published occupational therapy competency standards⁴ that recognise the unique cultural needs of Aboriginal and Torres Strait Islander peoples, and the need for occupational therapists to support their self-determination and quality of life. This is necessary to ensure that Aboriginal and Torres Strait Islander peoples will access occupational therapy services where they can be assured that communication will be respectful and therapists are aware of cultural issues. Specific competencies are in the following areas: (1) professionalism (that occupational therapists practise in a culturally responsive and culturally safe manner, and respond to historical, political, cultural, societal, environmental and economic factors influencing health, wellbeing and occupations of Aboriginal and Torres Strait Islander peoples); (2) knowledge and learning (that occupational therapists understand and respond to Aboriginal and Torres Strait Islander peoples’ health philosophies, leadership, research and practices); (3) occupational therapy process and practice (that occupational therapists seek to understand and incorporate Aboriginal and Torres Strait Islander peoples’ experiences of health, wellbeing and occupations encompassing cultural connections); and (4) communication (that occupational therapists work ethically with Aboriginal and Torres Strait Islander communities and organisations to understand and incorporate relevant cultural protocols and communication strategies). The study findings identified improved self-awareness and confidence, an appreciation of cultural practices and the capacity to recognise racism, which go some way to help students to meet these competencies prior to their graduation. Study participants identified elements of racism in the student cohort and within the community. Given that occupational therapy students are recruited from the general Australian population,^21,22 they may reflect the 75% of Australian society that has a bias against Aboriginal and Torres Strait Islander peoples.²³ Cultural insensitivity refers to more subtle forms of racism, also known as unconscious or implicit bias.²⁴ This can lead to unconscious prejudice and stereotypes that can negatively affect the health of Aboriginal and Torres Strait Islander peoples. Findings indicated that students reflected on their own cultural values during the module, such as realising their positions of privilege, which were previously not acknowledged,²⁵ and how this might influence their professional relationships with Aboriginal and Torres Strait Islander clients. These issues need to be discussed in a way that does not cause harm and assists students to move forward in a positive way. Self-reflection is the basis of cultural humility²⁶ and culturally safe practice, and enables a more client-centred approach and therefore better client rapport.²⁷ A process of learning about historical trauma, power, privilege and systemic inequality with the goal of students questioning their pre-existing views has been referred to as a ‘pedagogy of discomfort’.²³ For some study participants, exposure to Aboriginal and Torres Strait Islander peoples’ issues was a distressing experience, which is consistent with other studies^17,28 and is the opportunity to critically reflect and learn. This finding underlines the need to ensure a safe learning environment balanced with the need to address potentially confronting material. Negative experiences were described by study participants, however these were often related to other students in the group expressing offensive opinions. It appears that students with negative attitudes did not volunteer to participate in the interviews, therefore these could not be explored directly.

Confidence was an issue for students who had little experience of Aboriginal and Torres Strait Islander communities. Qualified health professionals in clinical practice also report a lack of confidence, citing feelings of frustration, a lack of training, being overwhelmed and having a sense of not knowing what they do not know.²⁹ Professional organisations, universities and employers need to provide opportunities for health professionals to develop their professional capacity and confidence. In the time since this study was conducted the University of Sydney has incorporated more Aboriginal and Torres Strait Islander curriculum content in both the undergraduate and Master’s programs. The Occupational Therapy staff have recently completed a 16 month cultural responsiveness mentoring program with Indigenous Allied Health Australia. This program aimed to support academic staff in their cultural responsiveness journey, strengthen their capacity to grow curriculum content on Aboriginal and Torres Strait Islander people’s wellbeing, and challenge the way in which occupational therapy services are delivered.

The module that was the subject of this study was developed and presented by non-Aboriginal and Aboriginal academics and expert contributors, and aligns with other recent studies. One study has described discipline-specific learning modules that aligned with the module for this study, which were presented to nursing, occupational therapy and dietetics students.³⁰ Student outcomes aligned with the findings of our study, in that students valued learning experiences and could explore their previous knowledge and enrich their understanding of Aboriginal history and culture. An international scoping review of multidisciplinary Indigenous cultural safety training³¹ found that in line with our study, workshops, discussions and immersion experiences were used, and most programs lasted 1–5 days. As in our study, student outcomes were evaluated by interviews in around 20% of articles, however, unlike our study only 20% of studies included a named Indigenous author.³¹ There remains little published evidence of education programs with regard to Aboriginal and Torres Strait Islander peoples’ health for occupational therapy students. This is also the case for physiotherapy students, and a unique program has been devised³² using a visit to the Melbourne Museum’s Bunjilaka gallery as an immersive experience, alongside similar classroom activities on cultural safety, health literacy, self-awareness of students’ own culture and health beliefs, and strategies for effective communication, as in our study.

Conclusion

The students who were interviewed had developed in their self-awareness and understanding of Aboriginal and Torres Strait Islander peoples’ issues of relevance to occupational therapy. Further work needs to be done to evaluate educational activities with occupational therapy and health professional students across Australia, and the health professions in general.

Supplementary material

Supplementary material is available online.