Systematic review of Indigenous cultural safety training interventions for healthcare professionals in Australia, Canada, New Zealand and the United States

A qualitative evaluation of rural and provincial surgery wānanga to enhance cultural safety among surgical registrars in Taranaki, New Zealand

BACKGROUND

The Royal Australasian College of Surgeons (RACS) recently instituted cultural safety and cultural competency as its 10th competency with formalized cultural safety training yet to be instituted. Wānanga are Indigenous Māori teaching institutions that can be used contemporarily for cultural safety training.

METHODS

In 2022, surgical registrars based at Taranaki Base Hospital (TBH) held in-hospital wānanga ranging from 1 to 3 h focussed on cultural safety, professionalism and wellbeing. This study explores the perspectives of these registrars who attended wānanga using a Kaupapa Māori aligned methodological stance and interpretive phenomenological analysis.

RESULTS

Twenty-six wānanga were held from March 22nd 2022 to January 30th 2023. Six registrars provided their perspectives with four major themes emerging from their stories including: cultural safety; unity; time, place and person; and a new era. Registrars valued the wānanga which was scheduled for Friday afternoons after daily clinical duties. Wānanga facilitated unity and understanding with registrars being able to reflect on the context within which they are practicing - describing it as a new era of surgical training. 'Time' was the biggest barrier to attend wānanga however, the number of wānanga held was testament to the commitment of the registrars.

CONCLUSIONS

Regular wānanga set up by, and for, surgical registrars cultural safety development is feasible and well subscribed in a rural or provincial NZ setting. We present one coalface method of regular cultural safety training and development for surgical registrars and trainees in NZ.

Māori experiences of physical rehabilitation in Aotearoa New Zealand: a scoping review

PURPOSE

The purpose of this review was to explore what is currently known about Māori experiences of physical rehabilitation services in Aotearoa New Zealand.

METHODS

A scoping review was undertaken following steps described by the Joanna Briggs Institute. Databases and grey literature were searched for qualitative studies that included descriptions of Māori consumer experiences in their encounters with physical rehabilitation. Data relating to study characteristics were synthesised. Qualitative data were extracted and analysed using reflexive thematic analysis.

RESULTS

Fourteen studies were included in this review. Four themes were generated that describe Māori experiences of rehabilitation. The first theme captures the expectations of receiving culturally unsafe care that become a reality for Māori during rehabilitation. The second theme describes whānau as crucial for navigating the culturally alien world of rehabilitation. The third theme offers solutions for the incorporation of culturally appropriate Māori practices. The final theme encompasses solutions for the provision of rehabilitation that empowers Māori.

CONCLUSIONS

This scoping review highlights ongoing inequities experienced by Māori when engaging with rehabilitation services. Strategies for facilitating culturally safe rehabilitation for Māori have been proposed. It is essential that rehabilitation clinicians and policymakers implement culturally safe approaches to rehabilitation with a view to eliminating inequities in care provision and outcomes for Māori.

Improving Indigenous health equity within the emergency department: a global review of interventions

INTRODUCTION

Indigenous health equity interventions situated within emergency care settings remain underexplored, despite their potential to influence patient care satisfaction and empowerment. This study aimed to systematically review and identify Indigenous equity interventions and their outcomes within acute care settings, which can potentially be utilized to improve equity within Canadian healthcare for Indigenous patients.

METHODS

A database search was completed of Medline, PubMed, Embase, Google Scholar, Scopus and CINAHL from inception to April 2023. For inclusion in the review, articles were interventional and encompassed program descriptions, evaluations, or theoretical frameworks within acute care settings for Indigenous patients. We evaluated the methodological quality using both the Joanna Briggs Institute checklist and the Ways Tried and True framework.

RESULTS

Our literature search generated 122 publications. 11 articles were selected for full-text review, with five included in the final analysis. Two focusing on Canadian First Nations populations and three on Aboriginal Australians. The main intervention strategies included cultural safety training, integration of Indigenous knowledge into care models, optimizing waiting-room environments, and emphasizing sustainable evaluation methodologies. The quality of the interventions was varied, with the most promising studies including Indigenous perspectives and partnerships with local Indigenous organizations.

CONCLUSIONS

Acute care settings, serving as the primary point of access to health care for many Indigenous populations, are well-positioned to implement health equity interventions such as cultural safety training, Indigenous knowledge integration, and optimization of waiting room environments, combined with sustainable evaluation methods. Participatory discussions with Indigenous communities are needed to advance this area of research and determine which interventions are relevant and appropriate for their local context.

Exploring how Australian general practice registrars define cultural safety with Aboriginal and Torres Strait Islander patients: a mixed method study

BACKGROUND

Understanding how the general practice medical workforce defines cultural safety may help tailor education and training to better enable community-determined culturally safe practice. This project seeks to explore how Australian general practice registrars define cultural safety with Aboriginal and Torres Strait Islander patients and alignment with an Australian community derived definition of cultural safety.

METHODS

This mixed method study involved a survey considering demographic details of general practice registrars, questionnaire, and semi-structured interviews to explore how general practice registrars defined cultural safety and a culturally safe consultation.

RESULTS

Twenty-six registrars completed the survey. Sixteen registrars completed both the survey and the interview.

CONCLUSION

This study shows amongst this small sample that there is limited alignment of general practice registrars' definitions of cultural safety with a community derived definition of cultural safety. The most frequently cited aspects of cultural safety included accessible healthcare, appropriate attitude, and awareness of differences.

Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training

BACKGROUND

Health care routinely fails Indigenous peoples and anti-Indigenous racism is common in clinical encounters. Clinical training programs aimed to enhance Indigenous cultural safety (ICS) rely on learner reported impact assessment even though clinician self-assessment is poorly correlated with observational or patient outcome reporting. We aimed to compare the clinical impacts of intensive and brief ICS training to control, and to assess the feasibility of ICS training evaluation tools, including unannounced Indigenous standardized patient (UISP) visits.

METHOD

Using a prospective parallel group three-arm randomized controlled trial design and masked standardized patients, we compared the clinical impacts of the intensive interactive, professionally facilitated, 8- to10-h Sanyas ICS training; a brief 1-h anti-bias training adapted to address anti-Indigenous bias; and control continuing medical education time-attention matched to the intensive training. Participants included 58 non-Indigenous staff physicians, resident physicians and nurse practitioners from family practice clinics, and one emergency department across four teaching hospitals in Toronto, Canada. Main outcome measures were the quality of care provided during UISP visits including adjusted odds that clinician would be recommended by the UISP to a friend or family member; mean item scores on patient experience of care measure; and clinical practice guideline adherence for NSAID renewal and pain assessment.

RESULTS

Clinicians in the intensive or brief ICS groups had higher adjusted odds of being highly recommended to friends and family by standardized patients (OR 6.88, 95% CI 1.17 to 40.45 and OR 7.78, 95% CI 1.05 to 58.03, respectively). Adjusted mean item patient experience scores were 46% (95% CI 12% to 80%) and 40% (95% CI 2% to 78%) higher for clinicians enrolled in the intensive and brief training programs, respectively, compared to control. Small sample size precluded detection of training impacts on clinical practice guideline adherence; 100% of UISP visits were undetected by participating clinicians.

CONCLUSIONS

Patient-oriented evaluation design and tools including UISPs were demonstrated as feasible and effective. Results show potential impact of cultural safety training on patient recommendation of clinician and improved patient experience. A larger trial to further ascertain impact on clinical practice is needed.

TRIAL REGISTRATION

Clinicaltrials.org NCT05890144. Retrospectively registered on June 5, 2023.

Evaluating the Effectiveness of Indigenous Health Curricula: Validation and Application of the NOSM CAST Instrument

OBJECTIVES

In recent years, Indigenous health curricula have been integrated into medical education in response to international calls to improve Indigenous health care. Instruments to evaluate Indigenous health education are urgently needed. We set out to validate a tool to measure self-reported medical student preparedness to provide culturally safe care to Indigenous Peoples. We then applied the tool to evaluate the effectiveness of the Northern Ontario School of Medicine University's (NOSM U) Indigenous health curriculum.

METHODS

We conducted psychometric testing of a 46-item draft NOSM Cultural Competency and Safety Tool (CAST). Testing included principal components analysis, subscale and item analysis, and the use of paired sample t-tests to examine pre- and posttest change to measure learner outcomes. The NOSM CAST was transposed to create a retrospective pre-posttest survey with single-point-in-time scoring.

RESULTS

Respondents included five cohorts of first-year undergraduate medical students, with 305 of 320 participating (response rate of 95.3%). The validated survey subscales included knowledge, confidence/preparedness, attitudes, intentions for advocacy, antidiscrimination, and self-reflective practice, measured using 36 scale items. Cronbach's alpha showed good to excellent internal consistency for the scales (α range = 0.82-0.91). Composite reliability values were acceptable. The pre-posttest analysis showed statistically significant increases on four scales: knowledge [t(254) = 15.10, P < .001], confidence/preparedness [t(254) = 15.85, P < .001], intentions for advocacy [t(251) = 3.32, P = .001], and self-reflective practice [t(254) = 8.04, P < .001]. The largest mean increases were for knowledge (d = 1.07) and confidence/preparedness (d = 1.15).

CONCLUSIONS

The NOSM CAST tracks student progress in Indigenous health curricula. NOSM U's classroom and immersion-based Indigenous health curriculum enhanced students' self-reported preparedness for culturally safe care. NOSM CAST implemented together with an assessment of Indigenous patient experiences with the same learners constitutes a rigorous evaluation approach to Indigenous health curricula.