"How can I do more?" Cultural awareness training for hospital-based healthcare providers working with high Aboriginal caseload

The nature and validity of implicit bias training for health care providers and trainees: A systematic review

The number of health care educational institutions/organizations adopting implicit bias training is growing. Our systematic review of 77 studies (published 1 January 2003 through 21 September 2022) investigated how implicit bias training in health care is designed/delivered and whether gaps in knowledge translation compromised the reliability and validity of the training. The primary training target was race/ethnicity (49.3%); trainings commonly lack specificity on addressing implicit prejudice or stereotyping (67.5%). They involved a combination of hands-on and didactic approaches, lasting an average of 343.15 min, often delivered in a single day (53.2%). Trainings also exhibit translational gaps, diverging from current literature (10 to 67.5%), and lack internal (99.9%), face (93.5%), and external (100%) validity. Implicit bias trainings in health care are characterized by bias in methodological quality and translational gaps, potentially compromising their impacts.

Patient clinical and demographic factors associated with involuntary psychiatric admission in the northern territory top end

OBJECTIVE

Australia has inadequate publicly available data regarding the use of involuntary psychiatric care. This study examined the association between patient clinical/demographic factors and involuntary psychiatric admission following initial psychiatric assessment in Royal Darwin Hospital.

METHOD

Retrospective review of 638 psychiatric assessments followed by covariate analysis of patient variables associated with involuntary psychiatric admission.

RESULTS

Most of the 225 psychiatric admissions were involuntary (92%). Male patients and those with a preferred language other than English had the highest risk of being admitted involuntarily (RR 1.09, χ2 [1] = 3.9, p = .048, and RR 1.11, p = .036, respectively).

CONCLUSIONS

Further research regarding the influence of patient demographics and clinical factors on rates of involuntary admissions, particularly for Aboriginal patients, is recommended. The findings prompt discussion on strategies to improve monitoring of involuntary care and barriers to voluntary treatment.

Perceived preparedness and training needs of new graduate physiotherapists' working with First Nations Australians

INTRODUCTION

There is a considerable and ongoing health gap experienced by First Nations Australians. Physiotherapists play an integral role in the health care of this population; however, little is known about new graduate preparedness and training needs to work in a First Nations context.

OBJECTIVE

To explore the perceptions of new graduate physiotherapists regarding their preparedness and training needs for working with First Nation Australians.

METHODS

Qualitative telephone, semi-structured interviews of new graduate physiotherapists (n = 13) who have worked with First Nations Australians in the last two years. Inductive, reflexive thematic analysis was used.

RESULTS

Five themes were generated: 1) limitations of pre-professional training; 2) benefits of work integrated learning; 3) 'on the job' development; 4) intrapersonal factors and efforts; and 5) insights into improving training.

CONCLUSION

New graduate physiotherapists perceive that their preparedness to work in a First Nations health context is supported by practical and varied learning experiences. At the pre-professional level, new graduates benefit from work integrated learning and opportunities that evoke critical self-reflection. At the professional level, new graduates express a need for 'on the job' development, peer supervision, and tailored professional development, that focuses on the unique perspectives of the specific community in which they work.

Birang Daruganora: what do Aboriginal and Torres Strait Islander communities need in a new hospital? A qualitative study

OBJECTIVES

To elicit the Aboriginal community's cultural and healthcare needs and views about six prominent and emerging models of care, to inform the development of a new hospital.

DESIGN

Cross-sectional qualitative study co-designed and co-implemented by Aboriginal team members.

SETTING

Western Sydney, New South Wales, Australia.

PARTICIPANTS

Aboriginal and Torres Strait Islander healthcare providers (n=2) and community members (n=18) aged between 21 and 60+ years participated in yarning circles (20 participants; 14 female, 6 male).

RESULTS

Handwritten notes from yarning circles were inductively analysed to synthesise the cultural and healthcare needs of providers and community members in relation to a new hospital and six models of care. Three primary themes emerged in relation to future hospitals. These were 'culturally responsive spaces', 'culturally responsive systems' and 'culturally responsive models of care'. Strengths (eg, comfort, reduced waiting time, holistic care), barriers (eg, logistics, accessibility, literacy) and enablers (eg, patient navigator role, communication pathways, streamlined processes) were identified for each of the six models of care.

CONCLUSIONS

Aboriginal and Torres Strait Islander community members and providers are invested in the co-creation of an innovative, well-integrated hospital that meets the needs of the community. Common themes of respect and recognition, relationships and partnering, and capacity building emerged as important consumer and provider considerations when developing and evaluating care services. Participants supported a range of models citing concerns about accessibility and choice when discussing evidence-based models of care.

Advancing health equity for Indigenous peoples in Canada: development of a patient complexity assessment framework

BACKGROUND

Indigenous patients often present with complex health needs in clinical settings due to factors rooted in a legacy of colonization. Healthcare systems and providers are not equipped to identify the underlying causes nor enact solutions for this complexity. This study aimed to develop an Indigenous-centered patient complexity assessment framework for urban Indigenous patients in Canada.

METHODS

A multi-phased approach was used which was initiated with a review of literature surrounding complexity, followed by interviews with Indigenous patients to embed their lived experiences of complexity, and concluded with a modified e-Delphi consensus building process with a panel of 14 healthcare experts within the field of Indigenous health to identify the domains and concepts contributing to health complexity for inclusion in an Indigenous-centered patient complexity assessment framework. This study details the final phase of the research.

RESULTS

A total of 27 concepts spanning 9 domains, including those from biological, social, health literacy, psychological, functioning, healthcare access, adverse life experiences, resilience and culture, and healthcare violence domains were included in the final version of the Indigenous-centered patient complexity assessment framework.

CONCLUSIONS

The proposed framework outlines critical components that indicate the presence of health complexity among Indigenous patients. The framework serves as a source of reference for healthcare providers to inform their delivery of care with Indigenous patients. This framework will advance scholarship in patient complexity assessment tools through the addition of domains not commonly seen, as well as extending the application of these tools to potentially mitigate racism experienced by underserved populations such as Indigenous peoples.

"Putting the power back into community": A mixed methods evaluation of a chronic hepatitis B training course for the Aboriginal health workforce of Australia's Northern Territory

BACKGROUND

Chronic hepatitis B (CHB) is endemic in the Aboriginal and Torres Strait Islander population of Australia's Northern Territory. Progression to liver disease can be prevented if holistic care is provided. Low health literacy amongst health professionals is a known barrier to caring for people living with CHB. We co-designed and delivered a culturally safe "Managing hepatitis B" training course for the Aboriginal health workforce. Here, we present an evaluation of the course.

OBJECTIVES

1. To improve course participants CHB-related knowledge, attitudes, and clinical practice. 2. To evaluate the "Managing hepatitis B" training course. 3. To enable participants to have the skills and confidence to be part of the care team.

METHODS

We used participatory action research and culturally safe principles. We used purpose-built quantitative and qualitative evaluation tools to evaluate our "Managing hepatitis B" training course. We integrated the two forms of data, deductively analysing codes, grouped into categories, and assessed pedagogical outcomes against Kirkpatrick's training evaluation framework.

RESULTS

Eight courses were delivered between 2019 and 2023, with 130 participants from 32 communities. Pre- and post-course questionnaires demonstrated statistically significant improvements in all domains, p<0.001 on 93 matched pairs. Thematic network analysis demonstrated high levels of course acceptability and significant knowledge acquisition. Other themes identified include cultural safety, shame, previous misinformation, and misconceptions about transmission. Observations demonstrate improvements in post-course engagement, a deep understanding of CHB as well as increased participation in clinical care teams.

CONCLUSIONS

The "Managing hepatitis B" training course led to a sustained improvement in the knowledge and attitudes of the Aboriginal health workforce, resulting in improved care and treatment uptake for people living with CHB. Important non-clinical outcomes included strengthening teaching and leadership skills, and empowerment.

Evaluating the impact of 'Ask the Specialist Plus': a training program for improving cultural safety and communication in hospital-based healthcare

BACKGROUND

First Nations peoples in colonised countries often feel culturally unsafe in hospitals, leading to high self-discharge rates, psychological distress and premature death. To address racism in healthcare, institutions have promised to deliver cultural safety training but there is limited evidence on how to teach cultural safety. To that end, we created Ask the Specialist Plus: a training program that focuses on improving healthcare providers intercultural communication skills to improve cultural safety. Our aim is to describe training implementation and to evaluate the training according to participants.

METHODS

Inspired by cultural safety, Critical Race Theory and Freirean pedagogy, Ask the Specialist Plus was piloted at Royal Darwin Hospital in Australia's Northern Territory in 2021. The format combined listening to an episode of a podcast called Ask the Specialist with weekly, one-hour face-to-face discussions with First Nations Specialists outside the clinical environment over 7 to 8 weeks. Weekly surveys evaluated teaching domains using five-point Likert scales and via free text comments. Quantitative data were collated in Excel and comments were collated in NVivo12. Results were presented following Kirkpatrick's evaluation model.

RESULTS

Fifteen sessions of Ask the Specialist Plus training were delivered. 90% of participants found the training valuable. Attendees enjoyed the unique format including use of the podcast as a catalyst for discussions. Delivery over two months allowed for flexibility to accommodate clinical demands and shift work. Students through to senior staff learnt new skills, discussed institutionally racist systems and committed to behaviour change. Considering racism is commonly denied in healthcare, the receptiveness of staff to discussing racism was noteworthy. The pilot also contributed to evidence that cultural safety should be co-taught by educators who represent racial and gender differences.

CONCLUSION

The Ask the Specialist Plus training program provides an effective model for cultural safety training with high potential to achieve behaviour change among diverse healthcare providers. The training provided practical information on how to improve communication and fostered critical consciousness among healthcare providers. The program demonstrated that training delivered weekly over two months to clinical departments can lead to positive changes through cycles of learning, action, and reflection.

Closing the gap in Indigenous Australian cancer care: Initiatives to foster cultural safety and improve access to radiation therapy

INTRODUCTION

Aboriginal and Torres Strait Islander peoples receive a poorer cancer prognosis compared to non-Indigenous Australians. Indigenous access to cancer care is limited by several factors, including differences in cultural understanding surrounding cancer and distrust of mainstream health institutions. It is believed that radiation therapy is being under-utilised by the Indigenous community. In response, several strategies were implemented to increase presentation and attendance by Indigenous Australians at a rural, private radiation therapy practice.

METHODS

A local Indigenous health service, Traditional Owners and Elders and the clinic's Reconciliation Action Plan Working Group were consulted to implement initiatives to reduce barriers to engaging in healthcare. One of these initiatives involved community consultation to select a culturally safe, Indigenous word to name one of the clinic's linear accelerators. Indigenous patient referrals into the clinic were tracked using an oncology information system. It is expected that by implementing several culturally safe strategies, there would be an increase in utilisation of the radiation therapy service and therefore, a decrease in Indigenous cancer burden across the local region. If strategies were yielding positive outcomes, there would be scope to implement these at other sites across a broader monitored network.

RESULTS

Currently, service utilisation is being monitored to determine whether initiatives have been successful. Initial data evaluation has been conducted and results are showing increased service utilisation by the Indigenous community.

CONCLUSION

Work has been undertaken to implement strategies to improve cultural safety and improve access to radiation therapy for Indigenous cancer patients. Preliminary results show an increase in the number of presentations to the clinic for radiation therapy treatment.

Clinical yarning education: development and pilot evaluation of an education program to improve clinical communication in Aboriginal health care - participant, and health manager perspectives

BACKGROUND

Effective communication between health care clinicians and Aboriginal patients is critical to delivering high quality, accessible, culturally secure health care. Despite this, ineffective communication is a well-documented barrier, and few studies have reported interventions to improve communication. Clinical Yarning is a patient centred communication framework for Aboriginal health care. Building on this framework, this study reports the development and evaluation of a Clinical Yarning education program.

METHODS

A Clinical Yarning education program was developed, underpinned by the principles of cultural security and adult learning, informed by a behavioural skills approach. The program was delivered in five health/education settings in one rural Western Australian region. Mixed-methods evaluation included a retrospective pre/post questionnaire to ascertain changes in participants' knowledge, confidence, competence and their perceptions about communication in Aboriginal health care, and the program. Qualitative semi-structured interviews were undertaken with health service managers who oversaw each health care setting and who had not participated in the education program, to explore perceptions about the program and implementation considerations.

RESULTS

Twenty-eight health care clinicians and six students completed training and the evaluation survey. There were significant improvements in self-rated communication skills, ability, confidence, knowledge, and perceived importance of communication training from pre to post-program. Participants strongly recommended the program to others, and most commonly valued the simulation/interactive learning activities. Health service managers acknowledged the limitations in most existing cultural training, and felt Clinical Yarning addressed a need; both the concept of Clinical Yarning and the education program provided were valued. Considerations identified for future implementation included: building multilevel partnerships within health services, offering alternate training options such as eLearning or train-the-trainer approaches, and integrating into existing development programs. Workforce transiency and availability were a barrier, particularly in remote areas.

CONCLUSIONS

This study offers preliminary support for the Clinical Yarning education program and provides a foundation for further development of this training approach. A future priority is implementation research to investigate the impact of the Clinical Yarning education program on health care and patient outcomes.

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

OBJECTIVE

To synthesise and appraise the design and impact of peer-reviewed evaluations of Indigenous cultural safety training programmes and workshops for healthcare workers in Australia, Canada, New Zealand and/or the United States.

DESIGN

Systematic review.

DATA SOURCES

Ovid Medline, Embase, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Bibliography of Indigenous Peoples in North America, Applied Social Sciences Index & Abstracts, ERIC (Education Resources Information Center), International Bibliography of the Social Sciences, ProQuest Dissertations & Theses Global, Sociological Abstracts, and Web of Science's Social Sciences Citation Index and Science Citation Index from 1 January 2006 to 12 May 2022.

ELIGIBILITY CRITERIA

Studies that evaluated the outcomes of educational interventions for selecting studies: designed to improve cultural safety, cultural competency and/or cultural awareness for non-Indigenous adult healthcare professionals in Canada, Australia, New Zealand or the United States.

DATA EXTRACTION AND SYNTHESIS

Our team of Indigenous and allied scientists tailored existing data extraction and quality appraisal tools with input from Indigenous health service partners. We synthesised the results using an iterative narrative approach.

RESULTS

2442 unique titles and abstracts met screening criteria. 13 full texts met full inclusion and quality appraisal criteria. Study designs, intervention characteristics and outcome measures were heterogeneous. Nine studies used mixed methods, two used qualitative methods and two used quantitative methods. Training participants included nurses, family practice residents, specialised practitioners and providers serving specific subpopulations. Theoretical frameworks and pedagogical approaches varied across programmes, which contained overlapping course content. Study outcomes were primarily learner oriented and focused on self-reported changes in knowledge, awareness, beliefs, attitudes and/or the confidence and skills to provide care for Indigenous peoples. The involvement of local Indigenous communities in the development, implementation and evaluation of the interventions was limited.

CONCLUSION

There is limited evidence regarding the effectiveness of specific content and approaches to cultural safety training on improving non-Indigenous health professionals' knowledge of and skills to deliver quality, non-discriminatory care to Indigenous patients. Future research is needed that advances the methodological rigour of training evaluations, is focused on observed clinical outcomes, and is better aligned to local, regional,and/or national Indigenous priorities and needs.

Healthcare professionals' cultural safety practices for indigenous peoples in the acute care setting - a scoping review

BACKGROUND

For Indigenous Peoples the disparities in health status are largely associated with the direct social determinants of invasion and colonisation, marginalisation, intergenerational traumas, and lack of conscious government policy to address these ongoing effects. There is currently limited evidence in the literature on what Cultural Safety practices mean in acute care settings.

OBJECTIVE

We aimed to understand the extent and type of evidence in relation to current knowledge and evidence regarding Cultural Safety practices for Indigenous Peoples in acute care settings.

DESIGN

This is a scoping review.

METHODS

We searched six databases in consultation with a librarian experienced in health research.

RESULTS

A total of 16 papers were included in the scoping review. Four main barriers to Cultural Safety in practice were identified; Among the included studies, only one quality improvement study reported an intervention, which improved culturally safe care.

CONCLUSION

The four barriers identified each have a variable impact on Indigenous Peoples' health outcomes and are dependent upon the circumstances and experiences of both Indigenous Peoples and healthcare professionals.

Improving outcomes for hospitalised First Nations peoples though greater cultural safety and better communication: the Communicate Study Partnership study protocol

BACKGROUND

The Communicate Study is a partnership project which aims to transform the culture of healthcare systems to achieve excellence in culturally safe care for First Nations people. It responds to the ongoing impact of colonisation which results in First Nations peoples experiencing adverse outcomes of hospitalisation in Australia's Northern Territory. In this setting, the majority of healthcare users are First Nations peoples, but the majority of healthcare providers are not. Our hypotheses are that strategies to ensure cultural safety can be effectively taught, systems can become culturally safe and that the provision of culturally safe healthcare in first languages will improve experiences and outcomes of hospitalisation.

METHODS

We will implement a multicomponent intervention at three hospitals over 4 years. The main intervention components are as follows: cultural safety training called 'Ask the Specialist Plus' which incorporates a locally developed, purpose-built podcast, developing a community of practice in cultural safety and improving access to and uptake of Aboriginal language interpreters. Intervention components are informed by the 'behaviour change wheel' and address a supply-demand model for interpreters. The philosophical underpinnings are critical race theory, Freirean pedagogy and cultural safety. There are co-primary qualitative and quantitative outcome measures: cultural safety, as experienced by First Nations peoples at participating hospitals, and proportion of admitted First Nations patients who self-discharge. Qualitative measures of patient and provider experience, and patient-provider interactions, will be examined through interviews and observational data. Quantitative outcomes (documentation of language, uptake of interpreters (booked and completed), proportion of admissions ending in self-discharge, unplanned readmission, hospital length of stay, costs and cost benefits of interpreter use) will be measured using time-series analysis. Continuous quality improvement will use data in a participatory way to motivate change. Programme evaluation will assess Reach, Effectiveness, Adoption, Implementation and Maintenance ('RE-AIM').

DISCUSSION

The intervention components are innovative, sustainable and have been successfully piloted. Refinement and scale-up through this project have the potential to transform First Nations patients' experiences of care and health outcomes.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov Protocol Record 2008644.

Yarning about pain: Evaluating communication training for health professionals at persistent pain services in Queensland, Australia

Background

Providing cultural education to health professionals is essential in improving the quality of care and outcomes for Aboriginal and Torres Strait Islander patients. This study reports the evaluation of a novel training workshop used as an intervention to improve communication with Aboriginal and Torres Strait Islander patients of persistent pain services.

Methods

In this single-arm intervention study, health professionals undertook a one-day workshop, which included cultural capability and communication skills training based on a clinical yarning framework. The workshop was delivered across three adult persistent pain clinics in Queensland. At the end of the training, participants completed a retrospective pre/post evaluation questionnaire (5 points Likert scale, 1 = very low to 5 = very high), to rate their perceived importance of communication training, their knowledge, ability and confidence to communicate effectively. Participants also rated their satisfaction with the training and suggested improvements for future trainings.

Results

Fifty-seven health professionals were trained (N = 57/111; 51% participation rate), 51 completed an evaluation questionnaire (n = 51/57; 90% response rate). Significant improvements in the perceived importance of communication training, knowledge, ability and confidence to effectively communicate with Aboriginal and Torres Strait Islander patients were identified (p < 0.001). The greatest increase was in the perceived confidence pre-training mean of 2.96 (SE = 0.11) to the post-training mean of 4.02 (SE = 0.09).

Conclusion

This patient-centred communication training, delivered through a novel model that combines cultural capability and the clinical yarning framework applied to the pain management setting, was highly acceptable and significantly improved participants' perceived competence. This method is transferrable to other health system sectors seeking to train their clinical workforce with culturally sensitive communication skills.

Suicides in Aboriginal and non-Aboriginal people following hospital admission for suicidal ideation and self-harm: A retrospective cohort data linkage study from the Northern Territory

PURPOSE

This study aimed to explore risk factors for suicide in Aboriginal and non-Aboriginal people following hospital admission for suicidal ideation and self-harm in the Northern Territory, Australia to help clarify opportunities for improved care and intervention for these population groups.

METHODS

Individuals with at least one hospital admission involving suicidal ideation and/or self-harm between 1 July 2001 and 31 December 2013 were retrospectively recruited and followed up using linked mortality records to 31 December 2014. Survival analyses stratified by Indigenous status identified socio-demographic and clinical characteristics from index hospital admissions associated with suicide.

RESULTS

Just over half of the 4391 cohort members identified as Aboriginal (n = 2304; 52.4%). By 2014, 281 deaths were observed comprising 68 suicides, representing a 2.6% and 2.0% probability of suicide for Aboriginal and non-Aboriginal people, respectively. After adjusting for other characteristics, a higher risk of suicide was associated with male sex (Aboriginal adjusted hazard ratio: 4.14; 95% confidence interval: [1.76, 9.75]; non-Aboriginal adjusted hazard ratio: 5.96; 95% confidence interval: [1.98, 17.88]) and repeat hospital admissions involving self-harm (Aboriginal adjusted hazard ratio: 1.37; 95% confidence interval: [1.21, 1.55]; non-Aboriginal adjusted hazard ratio: 1.29; 95% confidence interval: [1.10, 1.51]). Severe mental disorders were associated with a four times higher risk of suicide (adjusted hazard ratio: 4.23; 95% confidence interval: [1.93, 9.27]) in Aboriginal people only.

CONCLUSION

The findings highlight non-clinical risk factors for suicide that suggest the need for comprehensive psychosocial assessment tailored to Aboriginal and non-Aboriginal people hospitalised with suicidal ideation or self-harm. Implementing appropriate management and aftercare within a broader public health framework is needed to support recovery and reduce long-term suicide risk in the community, especially for Aboriginal people and males.

Evaluation of 'Ask the Specialist': a cultural education podcast to inspire improved healthcare for Aboriginal peoples in Northern Australia

In Australia's Northern Territory (NT) most people who access health services are Aboriginal and most healthcare providers are non-Indigenous; many providers struggle to deliver culturally competent care. Cultural awareness training is offered however, dissatisfaction exists with the limited scope of training and the face-to-face or online delivery format. Therefore, we developed and evaluated Ask the Specialist: Larrakia, Tiwi and Yolŋu stories to inspire better healthcare, a cultural education podcast in which Aboriginal leaders of Larrakia, Tiwi and Yolŋu nations, known as the Specialists, answer doctors' questions about working with Aboriginal patients. The Specialists offer 'counterstories' which encourage the development of critical consciousness thereby challenging racist narratives in healthcare. After listening to the podcast, doctors reported attitudinal and behavioural changes which led to stereotypes being overturned and more culturally competent care delivery. While the podcast was purposefully local, issues raised had applicability beyond the NT and outside of healthcare. Our approach was shaped by cultural safety, critical race theory and Freirean pedagogy. This pilot is embedded in a Participatory Action Research study which explores strategies to improve culturally safe communication at the main NT hospital Royal Darwin Hospital.

The Daalbirrwirr Gamambigu (Safe Children) Model: Embedding Cultural Safety in Child Protection Responses for Australian Aboriginal Children in Hospital Settings

The aim of this paper is to describe the development of a model of care to embed cultural safety for Aboriginal children into paediatric hospital settings. The Daalbirrwirr Gamambigu (pronounced "Dahl-beer-weer gum-um-be-goo" in the Gumbaynggirr language means 'safe children') model encompasses child protection responses at clinical, managerial and organisational levels of health services. A review of scholarly articles and grey literature followed by qualitative interviews with Aboriginal health professionals formed the evidence base for the model, which then underwent rounds of consultation for cultural suitability and clinical utility. Culturally appropriate communication with children and their families using clinical yarning and a culturally adapted version of ISBAR (a mnemonic for Identify, Situation, Background, Assessment and Recommendation) for interprofessional communication is recommended. The model guides the development of a critical consciousness about cultural safety in health care settings, and privileges the cultural voices of many diverse Aboriginal peoples. When adapted appropriately for local clinical and cultural contexts, it will contribute to a patient journey experience of respect, dignity and empowerment.

Clinician Perspectives of Communication with Aboriginal and Torres Strait Islanders Managing Pain: Needs and Preferences

Poor communication is an important factor contributing to health disparity. This study sought to investigate clinicians’ perspectives about communicating with Aboriginal and Torres Strait Islander patients with pain. This multi-site and mixed-methods study involved clinicians from three pain management services in Queensland, Australia. Clinicians completed a survey and participated in focus groups. Clinicians rated the importance of communication training, their knowledge, ability, and confidence in communicating with Aboriginal and Torres Strait Islander patients using a 5-point Likert scale. Rating scores were combined into low (scores 1–2); moderate (score 3) and high (scores 4–5). Informed by an interpretive description methodology, thematic analysis of focus group data was used to identify the communication needs and training preferences of clinicians. Overall (N = 64), 88% of clinicians rated the importance of communication training when supporting Aboriginal and Torres Strait Islander patients as “high”. In contrast, far fewer clinicians rated as “high” their knowledge (28%), ability (25%) and confidence (28%) in effectively communicating with Aboriginal and Torres Strait Islander patients. Thematic analysis identified three areas of need: knowledge of Aboriginal and Torres Strait Islander cultures, health beliefs, and understanding cross-cultural cues. Communication skills can be learned and training, in the form of a tailored intervention to support quality engagement with Aboriginal and Torres Strait Islander patients, should combine cultural and communication aspects with biomedical knowledge.

Does improved interpreter uptake reduce self-discharge rates in hospitalised patients? A successful hospital intervention explained

BACKGROUND

Aboriginal language interpreters are under-utilised in healthcare in northern Australia. Self-discharge from hospital is an adverse outcome occurring at high rates among Aboriginal people, with poor communication thought to be a contributor. We previously reported increased Aboriginal interpreter uptake and decreased rates of self-discharge during implementation of a 12-month hospital-based intervention. Interrupted time-series analysis showed sudden increase and up-trending improvement in interpreter use, and a corresponding decrease in self-discharge rates, during a 12-month intervention period (April 2018-March 2019) compared with a 24-month baseline period (April 2016 -March 2018). This paper aims to investigate reasons for these outcomes and explore a potential causal association between study activities and outcomes.

METHODS

The study was implemented at the tertiary referral hospital in northern Australia. We used the Template for Intervention Description and Replication (TIDieR) as a framework to describe intervention components according to what, how, where, when, how much, tailoring, modifications and reach. Components of the study intervention were: employment of an Aboriginal Interpreter Coordinator, 'Working with Interpreters' training for healthcare providers, and championing of interpreter use by doctors. We evaluated the relative importance of intervention components according to TIDieR descriptors in relation to outcomes. Activities independent of the study that may have affected study findings were reviewed. The relationship between proportion of hospital separations among Aboriginal people ending in self-discharge and numbers of Aboriginal interpreter bookings made during April 2016-March 2019 was tested using linear regression. 'Working with Interpreters' training sessions were undertaken at a regional hospital as well as the tertiary hospital. Training evaluation comprised an anonymous online survey before the training, immediately after and then at six to eight months. Survey data from the sites were pooled for analysis.

RESULTS

Employment of the Aboriginal Interpreter Coordinator was deemed the most important component of the intervention, based on reach compared to the other components, and timing of the changes in outcomes in relation to the employment period of the coordinator. There was an inverse association between interpreter bookings and self-discharge rate among Aboriginal inpatients throughout the baseline and intervention period (p = 0.02). This association, the timing of changes and assessment of intercurrent activities at the hospital indicated that the study intervention was likely to be casually related to the measured outcomes.

CONCLUSIONS

Communication in healthcare can be improved through targeted strategies, with associated improvements in patient outcomes. Health services with high interpreter needs would benefit from employing an interpreter coordinator.

"The talking bit of medicine, that's the most important bit": doctors and Aboriginal interpreters collaborate to transform culturally competent hospital care

Background

In hospitals globally, patient centred communication is difficult to practice, and interpreters are underused. Low uptake of interpreters is commonly attributed to limited interpreter availability, time constraints and that interpreter-medicated communication in healthcare is an aberration. In Australia’s Northern Territory at Royal Darwin Hospital, it is estimated around 50% of Aboriginal patients would benefit from an interpreter, yet approximately 17% get access. Recognising this contributes to a culturally unsafe system, Royal Darwin Hospital and the NT Aboriginal Interpreter Service embedded interpreters in a renal team during medical ward rounds for 4 weeks in 2019. This paper explores the attitudinal and behavioural changes that occurred amongst non-Indigenous doctors and Aboriginal language interpreters during the pilot.

Methods

This pilot was part of a larger Participatory Action Research study examining strategies to achieve culturally safe communication at Royal Darwin Hospital. Two Yolŋu and two Tiwi language interpreters were embedded in a team of renal doctors. Data sources included interviews with doctors, interpreters, and an interpreter trainer; reflective journals by doctors; and researcher field notes. Inductive thematic analysis, guided by critical theory, was conducted.

Results

Before the pilot, frustrated doctors unable to communicate effectively with Aboriginal language speaking patients acknowledged their personal limitations and criticised hospital systems that prioritized perceived efficiency over interpreter access. During the pilot, knowledge of Aboriginal cultures improved and doctors adapted their work routines including lengthening the duration of bed side consults. Furthermore, attitudes towards culturally safe communication in the hospital changed: doctors recognised the limitations of clinically focussed communication and began prioritising patient needs and interpreters who previously felt unwelcome within the hospital reported feeling valued as skilled professionals. Despite these benefits, resistance to interpreter use remained amongst some members of the multi-disciplinary team.

Conclusions

Embedding Aboriginal interpreters in a hospital renal team which services predominantly Aboriginal peoples resulted in the delivery of culturally competent care. By working with interpreters, non-Indigenous doctors were prompted to reflect on their attitudes which deepened their critical consciousness resulting in behaviour change. Scale up of learnings from this pilot to broader implementation in the health service is the current focus of ongoing implementation research.

"You Can't Work with My People If You Don't Know How to": Enhancing Transfer of Care from Hospital to Primary Care for Aboriginal Australians with Chronic Disease

Indigenous Australians experience significantly poorer health compared to other Australians, with chronic disease contributing to two-thirds of the health gap. We report on an evaluation of an innovative model that leverages mainstream and Aboriginal health resources to enable safe, supported transfer of care for Aboriginal adults with chronic conditions leaving hospital. The multisite evaluation was Aboriginal-led and underpinned by the principles of self-determination and equity and Indigenous research protocols. The qualitative study documented processes and captured service user and provider experiences. We found benefits for patients and their families, the hospital and the health system. The new model enhanced the patient journey and trust in the health service and was a source of staff satisfaction. Challenges included staff availability, patient identification and complexity and the broader issue of cultural safety. Critical success factors included strong governance with joint cultural and clinical leadership and enduring relationships and partnerships at the service delivery, organisation and system levels. A holistic model of care, bringing together cultural and clinical expertise and partnering with Indigenous community organisations, can enhance care coordination and safety across the hospital-community interface. It is important to consider context as well as specific program elements in design, implementation and evaluation.

From "stuck" to satisfied: Aboriginal people's experience of culturally safe care with interpreters in a Northern Territory hospital

BACKGROUND

Globally, interpreters are underused by health providers in hospitals, despite 40 years of evidence documenting benefits to both patients and providers. At Royal Darwin Hospital, in Australia's Northern Territory, 60-90% of patients are Aboriginal, and 60% speak an Aboriginal language, but only approximately 17% access an interpreter. Recognising this system failure, the NT Aboriginal Interpreter Service and Royal Darwin Hospital piloted a new model with interpreters embedded in a renal team during medical ward rounds for 4 weeks in 2019.

METHODS

This research was embedded in a larger Participatory Action Research study examining cultural safety and communication at Royal Darwin Hospital. Six Aboriginal language speaking patients (five Yolŋu and one Tiwi), three non-Indigenous doctors and five Aboriginal interpreter staff were purposefully sampled. Data sources included participant interviews conducted in either the patient's language or English, researcher field notes from shadowing doctors, doctors' reflective journals, interpreter job logs and patient language lists. Inductive narrative analysis, guided by critical theory and Aboriginal knowledges, was conducted.

RESULTS

The hospital experience of Yolŋu and Tiwi participants was transformed through consistent access to interpreters who enabled patients to express their clinical and non-clinical needs. Aboriginal language-speaking patients experienced a transformation to culturally safe care. After initially reporting feeling "stuck" and disempowered when forced to communicate in English, participants reported feeling satisfied with their care and empowered by consistent access to the trusted interpreters, who shared their culture and worldviews. Interpreters also enabled providers to listen to concerns and priorities expressed by patients, which resulted in holistic care to address social determinants of health. This improved patient trajectories and reduced self-discharge rates.

CONCLUSIONS

A culturally unsafe system which restricted people's ability to receive equitable healthcare in their first language was overturned by embedding interpreters in a renal medical team. This research is the first to demonstrate the importance of consistent interpreter use for providing culturally safe care for Aboriginal patients in Australia.

Aboriginal patient and interpreter perspectives on the delivery of culturally safe hospital-based care

ISSUE ADDRESSED

Improving equitable delivery of health care for Aboriginal people in northern Australia is a priority. This study sought to gauge patient experiences of hospitalisation and to identify strategies to improve equity in health care for Aboriginal patients. Aims were to validate an experience of care survey and document advice from Aboriginal interpreters.

METHODS

Medical charts of Aboriginal patients were audited for documentation of language and interpreter use. Aboriginal inpatients were surveyed using an adapted Australian Hospital Patient Experience Question Set. Multiple-choice responses were compared with free-text comments to explore validity. Semi-structured interviews were conducted with Aboriginal interpreter staff.

RESULTS

In 68 charts audited, primary language was documented for only 30/68 (44%) people. Of 73 patient experience survey respondents, 49/73 (67%) indicated satisfaction with overall care; 64/73 (88%) indicated hospital staff communicated well in multiple-choice responses. Respondents who gave positive multiple-choice ratings nevertheless reported in free text responses concerns relating to social-emotional support, loneliness, racism and food. Key themes from interviews included the benefits to patients from accessing interpreters, benefits of hospital-based support for interpreters and the need for further service redesign.

CONCLUSIONS

Multiple-choice questions in the survey were of limited utility; respondents' free comments were more informative. Social and emotional wellbeing must be addressed in future experience-of-care evaluations. Aboriginal patients' language and cultural needs can be better met by improved systems approaches. Aboriginal interpreters are uniquely placed to advise on this. SO WHAT?: Improving health communication is critical to equitable and effective health care. Interventions must be driven by Aboriginal perspectives.