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Raising questions about the cultural competence of health professionals and services

The importance of developing culturally competent health professionals and services was explored at Congress Lowitja in Melbourne recently.

Marie McInerney reports:

Evidence of why we need culturally competent health professionals and services may be found in preliminary research which is showing different rates of unspecified diagnoses in major hospitals between Aboriginal and Torres Strait Islander and non-Indigenous patients.

Australian Catholic University’s Senior Lecturer in Public Health, Dr Michael Taylor, told Congress Lowitja that the data was raw and could have many explanations but still it raised questions that “assumptions, rather than diagnoses, are perhaps being made” when hospitals treat Aboriginal and Torres Strait Islander people.

The research was presented to a conference workshop on cultural competency in hospitals – that is, their ability to meet the needs of Aboriginal patients and their communities, with Victorian research finding that nearly one-third of Aboriginal participants reported experiencing racism in health settings.

“It is notable that a group of people who are traditionally left behind in almost every respect of health, whether it’s health outcomes or the services they receive, are suddenly ahead of non-Indigenous people in terms of specificity of certain diagnoses, such as renal failure, liver disease and alcohol abuse,” he said.

Dr Taylor has been working on a Lowitja Institute project to measure the incidence of adverse events in hospitals experienced by Aboriginal and Torres Strait Islander peoples using data from the Australian Institute of Health and Welfare.

In looking at nearly 5 million hospital admissions (almost 4 per cent involving Aboriginal and Torres Strait Islander people) across Australia, he admits he “almost accidentally” stumbled on the diagnosis issue when he put together the top 20 list of principal diagnoses of Aboriginal and Torres Strait Islander people (see table below) and noted how many unspecified conditions there were, compared to non-Indigenous patients.


Digging into the data revealed that, for example, 55 per cent of diagnoses of coagulopathies in admissions for Aboriginal and Torres Strait Islander people were unspecified, versus only 46 per cent for non-Indigenous patients (see table below).

More troubling, he said, was the difference for neurological conditions, with 51 per cent unspecified for Aboriginal and Torres Strait Islander patients against 33 per cent for non-Indigenous patients. Slight differences were also to be seen in cardiac arrhythmia, congestive heart failure and lymphoma.

The patterns then “went into reverse” for certain other conditions, such as renal failure, liver disease, and alcohol abuse, where diagnoses for Aboriginal and Torres Strait Islander patients showed higher rates of specificity (see table).

“When it comes to renal failure, only 10 per cent of is unspecified in Aboriginal and Torres Strait Islander people, whereas for non-Indigenous patients it’s closer to 20 per cent,” Taylor said.

“They could be just testing and diagnosing really thoroughly, but there is the possibility they’re assuming rather than diagnosing: to say ‘you’re an Aboriginal and Torres Strait Islander person, you have these symptoms, so it’s going to be this’.”

Dr Taylor said there were many caveats about the use of the hospital data, which was not designed and collected for research purposes but for payment of services.

There can also be many other factors behind unspecified diagnosis: diagnosis may not be complete when the patient leaves hospital, complexity and co-morbidity can be a reason some conditions are unspecified, and/or it indicates gaps in testing and documentation.

“At this stage, we can see and say is there is most definitely a difference between the two populations,” he said.

“What is actually going on in the background will be exceptionally complicated, but this is yet another health difference experienced by Aboriginal and Torres Strait Islander people that needs to be looked at urgently.”

See Dr Taylor’s full slide presentation here.

***

Improving the culture of hospitals project

The conference also heard about initiatives undertaken at St Vincent’s Hospital in Melbourne – in particular, using the continuous quality care (CQI) approach to improve services to Aboriginal and Torres Strait Islander patients in the Emergency Department.

According to John Willis, Mission Development & Social Justice Manager from St Vincent’s, the hospital formed a focus group of the different professional groups working in the department, and asked what they understood about Aboriginal and Torres Strait Islander patient care in their area, and what they knew themselves about Aboriginal culture.

From that, specific training resources were developed to address issues like:

  • not judging identity by appearance
  • understanding the more holistic Aboriginal concept of health
  • respecting the broader family ties in Aboriginal communities and how that might mean finding ways to accommodate more visitors in the ED
  • respect regarding using images of people who have died
  • knowing that some issues are specific or sacred to men or women, and that patients may prefer to be offered care from a particular gender.

Key to the success of the project, he said, was having Aboriginal Liaison Officers (ALOs) engaged in the whole process. For such projects, he suggested that effective ways to evaluable progress can include:

  • identification rates and accuracy
  • Discharge Against Medical Advice (DAMA)
  • Did Not Wait (DNW)
  • Left with only partial treatment
  • Aboriginal employment percentage
  • Staff completion rates of cultural awareness training
  • 48hr follow-up rates.

For this project, he said, the key measure has been the rate of Aboriginal and Torres Strait Islander patients leaving with only partial treatment. As can be seen from the slide below there are some good signs:


Another project at the hospital focuses on improving care and understanding among new social workers at the hospital.

New recruits begin with the message from the photo (L) that comes from Here is Jane, a video which challenges staff about what they know about Indigenous culture and health.

Other resources include:

  • a local Indigenous history and culture walking tour
  • visiting the local Aboriginal medical service
  • a lanyard developed with Aboriginal Liaison Officers that has a checklist on what they need to cover when they are working with Aboriginal people, particularly around discharge procedures for medication and follow up appointments (see this earlier conference post about the complex journeys many Aboriginal people take for health care.

“The whole idea of developing these resources and undertaking these projects is Indigenous and non-Indigenous working together, encouraging staff to liaise closely with the Aboriginal Liaison Officers and also with  the Aboriginal community,” Willis said.

“Things do change from the ground up in this space, I think, more than others.”

***

Other insights from the session

Alwin Chong, from the University of Adelaide, described the approach of one hospital to issues about identifying if patients were Aboriginal and Torres Strait islander people, with staff not wanting to ask, despite being mandated to do so, because some people became aggressive.

“When non-Aboriginal people got upset, asking ‘do I look black?’, they would call the supervisor to come and mediate. When an Aboriginal person became upset, they would call security.”

***

Raising questions

Cultural competence and similar concepts are well on the agenda for the health sector and health professionals now, but what questions aren’t we asking?

Wendy Edmondson, Associate Professor of Indigenous Health at Flinders University, raised some of them at the conference session. Here she and colleague Courtney Ryder, Lecturer in Indigenous Health, outline their concerns.

Wendy Edmondson and Courtney Ryder write:

The Australian health system is increasingly recognising the importance of a greater understanding of the needs of Aboriginal and Torres Strait Islander peoples by their employees, in order to provide culturally appropriate care, and promote improvement in health outcomes in order to ‘close the gap”.

But are they taking the right approaches to achieving this? While the numbers of Aboriginal and Torres Strait health professionals is increasing, there is still a critical need for non-Aboriginal health professionals to undertake professional development to ensure care is provided to effectively address the burden of ill-health experienced by Aboriginal and Torres Strait Islander peoples.

There is a plethora of terminology being used in health services policy, practice and professional development: cultural competence, cultural awareness, cultural sensitivity, cultural humility, etc. To confuse matters, there is often limited shared understanding of what these concepts mean.

Professional development, for example, often reflects an “othering” approach, whereby health practitioners learn about Aboriginal and Torres Strait history, society and culture, without being asked to consider the impact of their own cultures on the provision of care.

Such training may promote a checklist approach to care, outlining the ‘dos and don’ts’, and in doing so reinforce stereotypical notions of Aboriginal and Torres Strait Islander peoples.

The concept of Cultural Safety, originating through the work of Maori midwives in 2000, is slowly gaining traction in health education in universities, and in professional development in health services in Australia.

The Nursing Council of New Zealand (2005) summarises the principles of cultural safety as including the need for health professionals to reflect on practice, to minimise power differentials, engage in a discourse with patients, decolonise practice, and in not diminishing, demeaning or disempowering others through your actions.

The Australian health system should examine the potential of such training to improve the Aboriginal and Torres Strait Islander patient journey, and health outcomes.

Cultural Safety training asks tough questions about health care interactions, like:

  • Whose values are being valued?
  • Who has the power in the relationship with the patient?
  • Are we regardful of culture, or are we treating patients in a manner regardless of culture?
  • Are we framing our practice through the lens of Western medicine?

Participants in Cultural Safety training are asked to reflect on their own values, assumptions and stereotypes, and to explore issues of identity, power, privilege, whiteness, racism and discrimination.

They are asked to consider the notion of patient-centred care, whereby the recipient of the health care determines the safety and quality of the health care provided.

Cultural safety training may be a challenging experience as participants embark on an uncomfortable journey whereby they may feel guilt, shame and anger.

It is critical that teaching methodologies are developed to ensure a safe environment, which facilitates the development of reflective practice and critical thinking.

The training often proves to be a transformative learning process for participants whereby personal social responsibility and ethical accountability is challenged to produce a deep conscious shift in the thinking that translates into culturally-safe professional practice.

You can track the Congress Lowitja coverage here.

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