Towards (re)conciliation: (re)constructing relationships between indigenous health workers and nurses

"We're on the ground, we know what needs to be done": Exploring the role of Aboriginal Health Workers in primary health care

Background

Aboriginal Health Workers (AHWs) are core providers of primary health care (PHC) for First Nations peoples in Australia. However, the national AHW workforce is aging and in short supply. There is a poor understanding of the factors contributing to this attrition from the perspectives of AHWs themselves. This study aimed to systematically explore the current functioning and sustainability of AHWs in NSW PHC by amplifying AHW voices.

Materials and methods

This study was co-designed with three Aboriginal health services in NSW. It included a literature review exploring the role of AHWs in NSW, and yarns with AHWs and their supervisors at participating services. Yarning is an Indigenous approach to knowledge generation centered upon storytelling. The yarns were guided by the USAID-developed Community Health Worker Assessment and Improvement Matrix. Yarn transcripts were analyzed using cyclical thematic analysis to identify key facilitators and challenges for AHW practice.

Results

The yarns highlighted five categories of change that are required to ensure AHW sustainability: community connection, recognition, value, support, and an inclusive health system. The yarns revealed that there are both service- and system-level factors influencing each of these categories of change.

Conclusions

The lived experiences of AHWs in NSW emphasize five key categories of change that are required to ensure workforce sustainability. It is evident that a system-wide paradigm shift to better include holistic approaches to health is necessary to truly ensure sustainability. Co-designing similar studies with ACCHOs across NSW can help inform this change.

Unique knowledge, unique skills, unique role: Aboriginal and Torres Strait Islander Health Workers in Queensland, Australia

Aboriginal and Torres Strait Islander Health Workers (A&TSIHWs) are a professional cadre of Australian health workers typically located in primary care clinics. The role is one of only two that is ‘identified’— that is, it must be occupied by an Aboriginal and/or Torres Strait Islander person — and holds specific responsibilities in relation to advocating for facility-level cultural safety. However, lack of understanding of the distinctive skills, scope and value associated with the A&TSIHW role remains pervasive in the broader health workforce. Positioned to represent the perspective of those working as A&TSIHWs, and drawing on 83 in-depth interviews with A&TSIHWs and others, this qualitative study reports on the core functions and distinctive orientation of the role, and seeks to articulate its distinctive value in the modern Queensland health service. Findings highlight the multifaceted (generalist) nature of the A&TSIHW role, which comprises three core functions: health promotion, clinical service and cultural brokerage. Underpinning these cross-cutting functions, is the role’s unique orientation, defined by client-centredness and realised through Indigenous strengths based ways of knowing, being and doing. The findings highlight how the A&TSIHW role is one of the only mechanisms through which Aboriginal and Torres Strait Islander knowledge can be brought to bear on context-specific adaptations to routine health service practices; and through which the impacts of lack of cultural or self-awareness among some non-Indigenous health professionals can be mitigated. The complexity of such work in a government health system where a dominant biomedical culture defines what is valued and therefore resourced, is under-recognised and undervalued and contributes to pressures and stress that are potentially threatening the role's long-term viability.

The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability

This paper is a critical interpretive synthesis of community health workers (CHWs) and accountability in low-income and middle-income countries. The guiding questions were: What factors promote or undermine CHWs as accountability agents? (and) Can these factors be intentionally fostered or suppressed to impel health system accountability? We conducted an iterative search that included articles addressing the core issue of CHWs and accountability, and articles addressing ancillary issues that emerged in the initial search, such as 'CHWs and equity.'CHWs are intended to comprise a 'bridge' between community members and the formal health system. This bridge function is described in three key ways: service extender, cultural broker, social change agent. We identified several factors that shape the bridging function CHWs play, and thus, their role in fomenting health system accountability to communities, including the local political context, extent and nature of CHW interactions with other community-based structures, health system treatment of CHWs, community perceptions of CHWs, and extent and type of CHW unionisation and collectivisation.Synthesising these findings, we elaborated several analytic propositions relating to the self-reinforcing nature of the factors shaping CHWs' bridging function; the roles of local and national governance; and the human resource and material capacity of the health system. Importantly, community embeddedness, as defined by acceptability, social connections and expertise, is a crucial attribute of CHW ability to foment local government accountability to communities.

"We are everything to everyone": a systematic review of factors influencing the accountability relationships of Aboriginal and Torres Strait Islander health workers (AHWs) in the Australian health system

BACKGROUND

Health policy in Australia positions Aboriginal and Torres Strait Islander Health Workers (AHWs) as central to improving Aboriginal and Torres Strait Islander peoples' health, with high expectations of their contribution to closing the gap between Indigenous and non-Indigenous health outcomes. Understanding how AHWs' governance and accountability relationships influence their ability to address such health inequities has policy, programme and ethical significance. We sought to map the evidence of AHWs' experiences of accountability in the Australian health system.

METHODS

We followed an adapted qualitative systematic review process to map evidence on accountability relations in the published literature. We sought empirical studies or first-person accounts describing AHWs' experiences of working in government or Aboriginal community-controlled services anywhere in Australia. Findings were organised according to van Belle and Mayhew's four dimensions of accountability - social, political, provider and organisational.

RESULTS

Of 27 included studies, none had a primary focus on AHW governance or AHWs' accountability relationships. Nonetheless, selected articles provided some insight into AHWs' experiences of accountability across van Belle and Mayhew's four dimensions. In the social dimension, AHWs' sense of connection and belonging to community was reflected in the importance placed on AHWs' cultural brokerage and advocacy functions. But social and cultural obligations overlapped and sometimes clashed with organisational and provider-related accountabilities. AHWs described having to straddle cultural obligations (e.g. related to gender, age and kinship) alongside the expectations of non-Indigenous colleagues and supervisors which were underpinned by 'Western' models of clinical governance and management. Lack of role-clarity stemming from weakly constituted (state-based) career structures was linked to a system-wide misunderstanding of AHWs' roles and responsibilities - particularly the cultural components - acting as a barrier to AHWs working to their full capacity for the benefit of patients, broader society and their own professional satisfaction.

CONCLUSIONS

In literature spanning different geographies, service domains and several decades, this review found evidence of complexity in AHWs' accountability relationships that both affects individual and team performance. However, theoretically informed and systematic investigation of accountability relationships and related issues, including the power dynamics that underpin AHW governance and performance in often diverse settings, remains limited and more work in this area is required.

Voices from the margins Part 2: Narrative accounts of the support needs of Indigenous families experiencing violence

Part 2 focuses on the needs of informal supporters of rural Aboriginal women experiencing family violence. The strategies for strengthening support for Aboriginal families are presented. The participants identified the barriers to help seeking by Aboriginal women, the needs of Aboriginal families experiencing violence, and healing models necessary to deal positively with the past and present trauma experienced by Indigenous people in Australia.

Voices from the margins Part 1: Narrative accounts of Indigenous family violence

The needs of informal supporters of rural women surviving domestic violence from the supporter's perspective were explored through the use of storytelling. Eleven women were interviewed. Of those eleven, three informal supporters spoke about supporting Indigenous women in family violence. These three stories have been grouped as a separate cohort and are discussed in two papers. Of the women who told stories of supporting Aboriginal women, two were Indigenous and one was non Aboriginal, although her partner was Indigenous. It was clear from the stories told by these women that Indigenous family violence is situated in a context of a history and experience of colonisation and human rights abuses. Therefore, this article explores the context of Indigenous family violence and the second explores the strategies for strengthening support for Aboriginal families experiencing violence.

Quality improvement in practice: improving diabetes care and patient outcomes in Aboriginal Community Controlled Health Services

Background

Management of chronic disease, including diabetes, is a central focus of most Aboriginal Community Controlled Health Services (ACCHSs) in Australia. We have previously demonstrated that diabetes monitoring and outcomes can be improved and maintained over a 10-year period at Derby Aboriginal Health Service (DAHS). While continuous quality improvement (CQI) has been shown to improve service delivery rates and clinical outcome measures, the process of interpreting audit results and developing strategies for improvement is less well described. This paper describes the evaluation of care of patients with type 2 diabetes mellitus (T2DM) and features of effective CQI in ACCHSs in the remote Kimberley region of north Western Australia.

Methods

Retrospective audit of records for Aboriginal and Torres Strait Islander primary care patients aged ≥15 years with a confirmed diagnosis of T2DM at four Kimberley ACCHSs from 1 July 2011 to 30 June 2012. Interviews with health service staff and focus group discussions with patients post audit. Main outcome measures: diabetes care related activities, clinical outcome measures and factors influencing good diabetes related care and effective CQI.

Results

A total of 348 patients from the four ACCHSs were included in the study. Clinical care activities were generally high across three of the four health services (at least 71% of patients had cholesterol recorded, 89% blood pressure, 84% HbA_1c). Patients from DAHS had lower median cholesterol levels (4.4 mmol/L) and the highest proportion of patients meeting clinical targets for HbA_1c (31% v 16% ACCHS-3; P = 0.02). Features that facilitated good care included clearly defined staff roles for diabetes management, support and involvement of Aboriginal Health Workers, efficient recall systems, and well-coordinated allied health services. Effective CQI features included seamless and timely data collection, local ownership of the process, openness to admitting deficiencies and willingness to embrace change.

Conclusions

Well-designed health care delivery and CQI systems, with a strong sense of ownership over diabetes management led to increased service delivery rates and improved clinical outcome measures in ACCHSs. Locally run CQI processes may be more responsive to individual health services and more sustainable than externally driven systems.

Needs of Aboriginal and Torres Strait Islander clients residing in Australian residential aged-care facilities

This review was undertaken to identify evidence-based practice guidelines to support the care needs of Aboriginal and Torres Strait Islander clients residing in residential aged-care facilities. A systematic literature review was undertaken. An electronic search of online databases and subsequent manual retrieval process was undertaken to identify relevant reports and studies that explored interventions for care of an Aboriginal and Torres Strait Islander person. Very limited published material identified strategies necessary within residential aged care. Sixty-seven articles were considered for inclusion, and a subsequent review resulted in 34 being included due to direct alignment with the study aim. Strategies recommended within the review cover areas such as care, communication, palliative care, activities and the environment. Care for an Aboriginal and Torres Strait Islander person in an Australian residential aged-care facility requires a collaborative and individual approach. Cultural safety principles should be maintained across a culturally competent workforce. Aboriginal and Torres Strait Islander persons in care is a significant experience that should not be considered 'routine' as there is much to consider in the care of this person and their community.

Social gradients in the health of Indigenous Australians

The pattern of association between socioeconomic factors and health outcomes has primarily depicted better health for those who are higher in the social hierarchy. Although this is a ubiquitous finding in the health literature, little is known about the interplay between these factors among indigenous populations. We begin to bridge this knowledge gap by assessing evidence on social gradients in indigenous health in Australia. We reveal a less universal and less consistent socioeconomic status patterning in health among Indigenous Australians, and discuss the plausibility of unique historical circumstances and social and cultural characteristics in explaining these patterns. A more robust evidence base in this field is fundamental to processes that aim to reduce the pervasive disparities between indigenous and nonindigenous population health.

Closing the (service) gap: exploring partnerships between Aboriginal and mainstream health services

Background. Although effective partnerships between Aboriginal and mainstream health services are critical to improve Aboriginal health outcomes, many factors can cause these partnerships to be tenuous and unproductive. Understanding the elements of best practice for successful partnerships is essential. Methods. A literature review was conducted in 2009 using keyword searches of electronic databases. Sourced literature was assessed for relevance regarding the benefits, challenges, lessons learnt and factors contributing to successful Aboriginal and mainstream partnerships. Key themes were collated. Results. Although there is much literature regarding general partnerships generally, few specifically examine Aboriginal and mainstream health service partnerships. Twenty-four sources were reviewed in detail. Benefits include broadening service capacity and improving the cultural security of healthcare. Challenges include the legacy of Australia’s colonial history, different approaches to servicing clients and resource limitations. Recommendations for success include workshopping tensions early, building trust and leadership. Conclusion. Although successful partnerships are crucial to optimise Aboriginal health outcomes, failed collaborations risk inflaming sensitive Aboriginal–non-Aboriginal relationships. Factors supporting successful partnerships remind us to develop genuine, trusting relationships that are tangibly linked to the Aboriginal community. Failure to invest in this relational process and push forward with ‘business as usual’ can ultimately have negative ramifications on client outcomes. What is known about the topic? Partnerships between different health services have long been recognised as beneficial for broadening service capacity and using resources more effectively to improve client care. The current policy climate particularly recognises partnerships between Aboriginal and mainstream services as offering multiple benefits for improving the cultural and clinical capacity of health service delivery to Aboriginal clients. Yet many challenges face these arrangements, including tensions stemming from historical and current race relations, different ways of working and ongoing Aboriginal disadvantage. What does this paper add? Although partnerships between Aboriginal and mainstream services are strongly advocated for, there is a paucity of research on the challenges in these arrangements and practical suggestions on how to make such partnerships genuinely successful. This paper analyses the results from research, case studies, reports and reviews to identify the factors that challenge and enhance partnerships between Aboriginal and mainstream health services. The collation of this information also enables indicators of best practice to be presented. What are the implications for practitioners? Although there are considerable challenges for Aboriginal and mainstream health services entering into partnerships, this paper offers health service practitioners and managers a summary of lessons learnt and a ‘checklist’ of best practice indicators to assist them in developing, implementing and sustaining a successful collaborative arrangement.

Describing and analysing primary health care system support for chronic illness care in Indigenous communities in Australia's Northern Territory - use of the Chronic Care Model

Background

Indigenous Australians experience disproportionately high prevalence of, and morbidity and mortality from chronic illness such as diabetes, renal disease and cardiovascular disease. Improving the understanding of how Indigenous primary care systems are organised to deliver chronic illness care will inform efforts to improve the quality of care for Indigenous people.

Methods

This cross-sectional study was conducted in 12 Indigenous communities in Australia's Northern Territory. Using the Chronic Care Model as a framework, we carried out a mail-out survey to collect information on material, financial and human resources relating to chronic illness care in participating health centres. Follow up face-to-face interviews with health centre staff were conducted to identify successes and difficulties in the systems in relation to providing chronic illness care to community members.

Results

Participating health centres had distinct areas of strength and weakness in each component of systems: 1) organisational influence – strengthened by inclusion of chronic illness goals in business plans, appointment of designated chronic disease coordinators and introduction of external clinical audits, but weakened by lack of training in disease prevention and health promotion and limited access to Medicare funding; 2) community linkages – facilitated by working together with community organisations (e.g. local stores) and running community-based programs (e.g. "health week"), but detracted by a shortage of staff especially of Aboriginal health workers working in the community; 3) self management – promoted through patient education and goal setting with clients, but impeded by limited focus on family and community-based activities due to understaffing; 4) decision support – facilitated by distribution of clinical guidelines and their integration with daily care, but limited by inadequate access to and support from specialists; 5) delivery system design – strengthened by provision of transport for clients to health centres, separate men's and women's clinic rooms, specific roles of primary care team members in relation to chronic illness care, effective teamwork, and functional pathology and pharmacy systems, but weakened by staff shortage (particularly doctors and Aboriginal health workers) and high staff turnover; and 6) clinical information systems – facilitated by wide adoption of computerised information systems, but weakened by the systems' complexity and lack of IT maintenance and upgrade support.

Conclusion

Using concrete examples, this study translates the concept of the Chronic Care Model (and associated systems view) into practical application in Australian Indigenous primary care settings. This approach proved to be useful in understanding the quality of primary care systems for prevention and management of chronic illness. Further refinement of the systems should focus on both increasing human and financial resources and improving management practice.

Health professional partnerships and their impact on Aboriginal health: an occupational therapist's and Aboriginal health worker's perspective

OBJECTIVE

To describe the extent and nature of demonstrated professional partnerships between occupational therapists and Aboriginal health workers in rural and remote communities of North Queensland. The study identifies ways in which professional partnerships improve client services and enhance occupational therapy outcomes through exploring the aspects of communication, collaboration and bridging cultural boundaries.

DESIGN

Data collected via in-depth, semistructured telephone interviews.

SETTING

Aboriginal and mainstream health and human service organisations in rural and remote North Queensland. Rural and remote areas were identified using the Accessibility and Remoteness Index of Australia codes.

PARTICIPANTS

Seven participants working in rural and remote areas of North Queensland, comprising four occupational therapists and three Aboriginal health workers. All participants were female.

RESULTS

Participants identified five core themes when describing the extent and nature of professional partnerships between occupational therapists and Aboriginal health workers. Themes include: professional interaction; perception of professional roles; benefits to the client; professional interdependence; and significance of Aboriginal culture. According to participants, when partnerships between occupational therapists and Aboriginal health workers were formed, clients received a more culturally appropriate service, were more comfortable in the presence of the occupational therapist, obtained a greater understanding of occupational therapy assessment and intervention, and felt valued in the health care process.

CONCLUSIONS

This study substantiates the necessity for the formation of professional partnerships between occupational therapists and Aboriginal health workers. The findings suggest that participation in professional partnerships has positive implications for occupational therapists working with Aboriginal clients and Aboriginal health workers in rural and remote regions of North Queensland.

Aboriginal health workers and diabetes care in remote community health centres: a mixed method analysis

OBJECTIVE

To assess the effect of employing Aboriginal health workers (AHWs) on delivery of diabetes care in remote community health centres, and to identify barriers related to AHWs' involvement in diabetes and other chronic illness care.

DESIGN, SETTING AND PARTICIPANTS

Three-year follow-up study of 137 Aboriginal people with type 2 diabetes in seven remote community health centres in the Northern Territory.

MAIN OUTCOME MEASURES

Delivery of guideline-scheduled diabetes services; intermediate outcomes (glycated haemoglobin [HbA(1c)] and blood pressure levels); number and sex of AHWs at health centres over time; barriers to AHWs' involvement in chronic illness care.

RESULTS

There was a positive relationship between the number of AHWs per 1000 residents and delivery of guideline-scheduled diabetes services (but not intermediate health outcomes). Presence of male AHWs was associated with higher adherence to the guidelines. Barriers to AHWs' involvement in chronic illness care included inadequate training, lack of clear role divisions, lack of stable relationships with non-Aboriginal staff, and high demands for acute care.

CONCLUSIONS

Employing AHWs is independently associated with improved diabetes care in remote communities. AHWs have potentially important roles to play in chronic illness care, and service managers need to clearly define and support these roles.

An innovative nurse education program in the Torres Strait Islands

As the most numerous and geographically dispersed professional group, registered nurses in Australia work with Aboriginal and Torres Strait Islander health workers and other members of the multidisciplinary team in a variety of practice contexts to provide health care to Indigenous and non-Indigenous people. Despite the introduction of a variety of recruitment and proactive support strategies by employers, universities and State and Commonwealth governments, few Indigenous people in Australia enrol in, and graduate from, entry level higher education courses in the health professions. The reasons for this are complex and, as yet, not well understood or described; however, it is clear that the well-documented execrable health status of Indigenous Australians demands a response from universities, which are largely responsible for the education of health professionals. An innovative model of registered nurse education in the Torres Strait region of Australia is reported in this paper. A satellite campus established by James Cook University (JCU) on Thursday Island delivers the undergraduate nursing course by mixed mode, supplemented by specific strategies designed to improve Indigenous student recruitment and retention and thus increase the likelihood of graduation. The course and the strategies implemented are discussed in this paper.

Dealing with diversity: incorporating cultural sensitivity into professional midwifery practice

In the Australian College of Midwives, Code of Ethics, Section 11. Practice of Midwifery, the following is stated "A. Midwives provide care for women and childbearing families with respect for cultural diversity while also working to eliminate harmful practices within those same cultures." However, it is difficult to know what is meant by "respect for cultural diversity". This paper presents the results of a critical review of the health literature. There is surprisingly little consensus about the meaning of terms such as cultural sensitivity and cultural appropriate care. Nor are there reflections on incorporating these concepts into practice. It could be argued that until there is greater clarity about these concepts and more discussion of how they may be used in practice, midwives would have to continue to rely on their individual knowledge and experience.