Once again the debate about cultural safety has escalated nationally thru News Ltd newspapers with the Daily Telegraph leading off on Tuesday (3 April ) with a front page “cultural safety expose “ and 4 hours nonstop coverage and commentary on SkyNews from the usual suspects Peta Credlin , Alan Jones , Andrew Bolt , Ben Fordham , Paul Murray, Troy Branston in addition to blanket radio coverage across Australia.
See 2 SkyNews Broadcasts below
The policy issue being heavily criticised by the media but not health authorities and experts is that the NSW Health has recommended its emergency departments to provide “culturally appropriate space’’ for the families of Aboriginal patients.
The new policy in NSW to provide a “culturally appropriate space’’ or “designated Aboriginal waiting room’’ was introduced after research found Indigenous patients were at least 1.5 times more likely to leave hospitals before emergency treatment.
In Victoria some hospitals and services have separate areas for Indigenous patients and their families to meet, rest or engage with specialist hospital staff.
See Part 1 Below for NSW Health policy extracts and download document
Above Editorial Daily Telegraph 3 April
Firstly those in favour of this cultural safety policy include
” Well, I think it’s good that issues like cultural safety are entering the popular narrative. We need to do better when it comes to delivering care to Aboriginal and Torres Strait Islander people, and I think we need to ask them what will and won’t work.
The truth is that health outcomes for Indigenous Australians are significantly worse than non-Indigenous Australians according to just about every possible metric.
The AMA strongly supports Aboriginal control when it comes to primary care and when it comes to Aboriginal and Torres Strait Islanders being in larger health facilities like our hospitals, I think we need to do everything we can to make them- the appropriate settings for them to seek care.
If that means spending a little bit of money on waiting areas, if that means making subtle changes to outpatient clinics or to inpatient wards to make Indigenous people feel more at home, I don’t think non-Indigenous people should find that threatening”
1.Dr Michael Gannon President AMA
“For the Aboriginal and Torres Strait Islander population born in 2010–2012, life expectancy was estimated to be 10.6 years lower than that of the non-Indigenous population.
“Indigenous patients are over-represented in requiring public hospital services.
“In 2013-14, there were 392,142 public hospital emergency department presentations by Indigenous people, accounting for 5.4% of all such presentations.
As a doctor working in south western Sydney and at an Aboriginal Medical Service, I see every day the barriers to accessing healthcare faced by our Indigenous patients.
“Hospitals are complex, overwhelming places and care is too often fragmented.
“For this reason, everyone involved in healthcare has an obligation to break down the barriers to accessing care and to improve health outcomes.
2. AMA (NSW) President, Prof Brad Frankum
“ It isn’t mandatory in the sense they’ve got to do it, it’s mandatory in the sense you’ve got to think about what is culturally appropriate (and) what might help the local community,”
3.Health Minister Brad Hazzard said many hospitals had already decided to introduce a culturally appropriate space.
“Among other benefits, culturally competent care increases accurate and timely diagnosis and increases attendance rates at follow-up appointments
Positive results such as these worked to overcome reluctance to engage with mainstream healthcare services, as well as improving rates of self-discharge against medical advice.”
4.President Simon Judkins the Australasian College for Emergency Medicine said it believed emergency departments must move towards a place of respect and acknowledgment of Indigenous culture
The college also called for a focus on increasing the numbers of Aboriginal and Torres Strait Islander people working across all health professions, including emergency medicine.
“All healthcare providers need to consider the cultural dimension of the services they are providing, and embrace culturally safe care which is determined to be safe by Aboriginal and Torres Strait Islander patients and their families.
This includes making hospital waiting rooms a welcoming and supportive environment for Aboriginal and Torres Strait Islander people, which will help to build trust between them and their healthcare providers and enhance cultural sensitivity in medical treatment.
It is vitally important that these waiting areas are designed and implemented in close consultation with relevant local Aboriginal and Torres Strait Islander communities and Aboriginal Community Controlled Health Organisations.”
5.Carmen Parter, PHAA Vice-President (Aboriginal and Torres Strait Islander) affirmed PHAA’s support for such an initiative.
” The policy was about improving the health of Aboriginal people and people who are not Aboriginal should not be threatened by the fact we’re trying to look out for a very vulnerable part of our community ”
6.NSW Health deputy secretary Susan Pearce
” The policy is flexible, allowing local health districts to carry out initiatives in consultation with their local Aboriginal community to make their hospital settings more culturally inclusive, in ways that best suit the community,”
7.NSW Health spokeswoman .
“Within the hospital system Aboriginal and Torres Strait Islander people face racist barriers to gaining appropriate health care. Despite the increased burden of disease they carry, Aboriginal and Torres Strait Islander patients are only three-quarters (73%) as likely to undergo a procedure once admitted to hospital
Racism is a significant barrier to Aboriginal health improvement say Donna Ah Chee 2015 Read in full here or Part 4 Below
” Cultural safety requires embedding in not only course accreditation for each health profession — including measures to reduce resistance — but also in the standards governing clinical professionalism and quality, such as the Royal Australian College of General Practitioners Standards for general practices,19 and the Australian Commission on Safety and Quality in Health Care National safety and quality health service standards.20
Such commitment will need investment in clinician education and professional development, together with measures for accountability. The stewards of the National Aboriginal and Torres Strait Islander Health Plan5 (ie, the Department of Health and their expert implementation advisory group), accreditation bodies, and monitors of the existing frameworks of safety and quality standards in health care need to formally collaborate on a systematic revision of standards to embed culturally safe practice and develop health settings free of racism.”
Martin Laverty, Dennis R McDermott and Tom Calma see Part 5 Below
Part 1 NSW Policy
Download The Policy document in full
Local processes should be in place to monitor numbers of patients who ‘Did not Wait’ for treatment following triage, including rates for Aboriginal and non-Aboriginal patients.
Strategies to address issues identified should be implemented and evaluated
2.1.3 Considerations for Aboriginal patients
Section 4.1 acknowledges the higher rates of Aboriginal patients who choose not to wait for treatment in ED when compared to non-Aboriginal patients.
An important contributor to this issue is Aboriginal patients feeling safe to stay and wait. The use of local Aboriginal art in ED waiting rooms can provide links to culture and community; advice should be sought on appropriate art from the local Aboriginal community.
If available in the hospital, relatives may access the designated Aboriginal waiting room for families and carers. If no room exists, a culturally appropriate space within the local hospital should be identified.
Patients identifying as Aboriginal people should be provided with information regarding access to Aboriginal Health Workers that may be available. Access to any of these services may
4.1 Monitoring of rates of patients who ‘Did not Wait’
EDs should maintain a local auditing system to monitor trends in rates of DNW. Review of data should also be undertaken by Aboriginal and non-Aboriginal patients as there is significant evidence in the literature of higher rates of DNW among Aboriginal patients presenting to ED
Addressing this issue is in line with the Australian Commission on Safety and Quality in Healthcare’s guidance on Improving care for Aboriginal and Torres Strait Islander People.
Locally designed strategies to manage identified reasons for patients who DNW should be implemented with outcomes reviewed. Consideration may be given to follow up of patients who DNW who are considered to have high risk issues or are from a vulnerable patient group.
Part 2 AMA (NSW) President: culturally appropriate spaces in EDs are a welcome addition to NSW public hospitals
Access to healthcare is critical to the wellbeing of all Australians and removing barriers to it is important, AMA (NSW) President, Prof Brad Frankum, said.
“It is essential that hospitals and all healthcare facilities make an effort to provide safe and welcoming spaces to facilitate access to care.
“Public hospitals try to do this in a range of ways, including the design of spaces, the provision of information in different languages, access to translators and other services to ensure patients get the best from their healthcare.
“For this reason, AMA (NSW) applauds the NSW Government for encouraging hospitals to ensure that they consider the needs of Indigenous patients in creating a safe and welcoming environment in hospitals,” Prof Frankum said.
“Indigenous patients continue to suffer unacceptably poorer health outcomes compared to other Australians.
“For the Aboriginal and Torres Strait Islander population born in 2010–2012, life expectancy was estimated to be 10.6 years lower than that of the non-Indigenous population.
“Indigenous patients are over-represented in requiring public hospital services.
“In 2013-14, there were 392,142 public hospital emergency department presentations by Indigenous people, accounting for 5.4% of all such presentations,” Prof Frankum said.
“As a doctor working in south western Sydney and at an Aboriginal Medical Service, I see every day the barriers to accessing healthcare faced by our Indigenous patients.
“Hospitals are complex, overwhelming places and care is too often fragmented.
“For this reason, everyone involved in healthcare has an obligation to break down the barriers to accessing care and to improve health outcomes.
“It is disappointing to see those who clearly do not have the same personal experiences of navigating our healthcare system making inappropriate comments about such an important health policy,” Prof Frankum said
Part 3 : Culturally safe healthcare starts in the waiting room
The Public Health Association of Australia (PHAA) called for cultural safety in Aboriginal and Torres Strait Islander healthcare last week, along with a number of other leading health groups and medical practitioners.
As an extension of this, the PHAA supports all viable and suitable cultural safety measures in the provision of healthcare to Aboriginal and Torres Strait Islander people, including culturally appropriate waiting rooms.
Carmen Parter, PHAA Vice-President (Aboriginal and Torres Strait Islander) affirmed PHAA’s support for such an initiative, saying, “All healthcare providers need to consider the cultural dimension of the services they are providing, and embrace culturally safe care which is determined to be safe by Aboriginal and Torres Strait Islander patients and their families.”
“This includes making hospital waiting rooms a welcoming and supportive environment for Aboriginal and Torres Strait Islander people, which will help to build trust between them and their healthcare providers and enhance cultural sensitivity in medical treatment,” she said.
Ms Parter continued, “It is vitally important that these waiting areas are designed and implemented in close consultation with relevant local Aboriginal and Torres Strait Islander communities and Aboriginal Community Controlled Health Organisations.”
“The history of the stolen generations and the role that Australian hospitals held during these events has left a strong effect on Aboriginal and Torres Strait Islander people, and in order to overcome this and move toward Reconciliation we need to work together to ensure Australian hospitals are a safe space for all,” Ms Parter said.
Michael Moore, CEO of the PHAA supported Ms Parter’s statements, saying, “Evidence shows that healthcare has the best outcomes when the patient and provider can share knowledge and understanding in a respectful and welcoming environment.
We also know that Aboriginal and Torres Strait Islander patients are at least 1.5 times more likely to leave hospital before receiving treatment compared to non-Indigenous patients.”
“This resembles the gaps in health outcomes which Close the Gap campaigners are working hard to resolve, and a trial on the mid-north coast in NSW showed that culturally appropriate waiting rooms resulted in a 50% reduction in Aboriginal and Torres Strait Islander patients leaving before accessing treatment. This really demonstrates the strength of this type of cultural safety initiative in a tangible way,” Mr Moore said.
“We ensure that hospitals are safe environments for children, elderly people, disabled people, and other groups with certain needs, it’s now time we ensure that the cultural needs of patients are also taken into careful consideration,” Mr Moore said.
Part 4 Racism and the hospital system : Donna Ah Chee
“Within the hospital system Aboriginal and Torres Strait Islander people face racist barriers to gaining appropriate health care. Despite the increased burden of disease they carry, Aboriginal and Torres Strait Islander patients are only three-quarters (73%) as likely to undergo a procedure once admitted to hospital (3).
This difference led one key study to conclude that ‘there may be systematic differences in the treatment of patients identified as Indigenous’ in Australia’s public hospitals (4), a conclusion supported by studies showing poorer survival rates for cancer for Indigenous people, due to their being less likely to have treatment, having to wait longer for surgery, and being referred later for specialist treatment (5). This is not good enough and we need to use the current spotlight on racism to look at these deeper issues as well”, she suggested.
“Such systemic differences in care provided by hospitals contribute to Aboriginal and Torres Strait Islander people’s low level of trust for hospitals as institutions – the 2008 National Aboriginal and Torres Strait Islander Social Survey found that little more than 60% of Aboriginal and Torres Strait Islander people said that they felt hospitals could be trusted (6).
This level of distrust is reflected in the fact that Aboriginal and Torres Strait Islander people are five times as likely to leave hospital against medical advice or be discharged at their own risk compared to other Australians (7).
“Addressing these institutional barriers to appropriate care is complex but possible and we can do it as a nation of we finally come to terms with the seriousness of the problem (8).
“It will take a strong commitment to action. There needs to be a greater awareness in the Australian community about the adverse health consequences of racism for Aboriginal people.
If any good is to come out of the racism shown towards Adam Goodes I hope it is an awareness of the harm this does to our people across the nation which is currently symbolised by the suffering of one man: Adam Goodes.
Racism is a serious problem that Australia is yet to properly address. It should never be trivialised. It needs to be dealt with”, she concluded.
References
- Paradies, Y., Harris, R. & Anderson, I. 2008, The Impact of Racism on Indigenous Health in Australia and Aotearoa: Towards a Research Agenda, Discussion Paper No. 4, Cooperative Research Centre for Aboriginal Health, Darwin.
- ANTaR website http://www.antar.org.au/node/2… accessed September 26 2011
- Australian Health Ministers Advisory Council (2012). Aboriginal and Torres Strait Islander Health Performance Framework 2012 Report. AHMAC. Canberra. page 131
- Cunningham J (2002). “Diagnostic and therapeutic procedures among Australian hospital patients identified as Indigenous.” Medical Journal of Australia 176(2): 58-62
- Condon J R, Barnes T, et al. (2005). “Stage at diagnosis and cancer survival for Indigenous Australians in the Northern Territory.” Medical Journal of Australia 182(6
” Cultural safety requires embedding in not only course accreditation for each health profession — including measures to reduce resistance — but also in the standards governing clinical professionalism and quality, such as the Royal Australian College of General Practitioners Standards for general practices,19 and the Australian Commission on Safety and Quality in Health Care National safety and quality health service standards.20
Such commitment will need investment in clinician education and professional development, together with measures for accountability. The stewards of the National Aboriginal and Torres Strait Islander Health Plan5 (ie, the Department of Health and their expert implementation advisory group), accreditation bodies, and monitors of the existing frameworks of safety and quality standards in health care need to formally collaborate on a systematic revision of standards to embed culturally safe practice and develop health settings free of racism.”
Martin Laverty, Dennis R McDermott and Tom Calma
Originally published by MJA here
Download a PDF of this Report Paper for references 1-20
Read 20 + previous NACCHO articles Cultural Safety
In Australia, the existing health safety and quality standards are insufficient to ensure culturally safe care for Indigenous patients in order to achieve optimum care outcomes.
Where “business as usual” health care is perceived as demeaning or disempowering — that is, deemed racist or culturally unsafe — it may significantly reduce treatment adherence or result in complete disengagement,1,2 even when this may be life-threatening.3
Peak Indigenous health bodies argue that boosting the likelihood of culturally safe clinical care may substantially contribute to Indigenous health improvement.4 It follows that a more specific embedding of cultural safety within mandatory standards for safe, quality-assured clinical care may strengthen the currently inadequate Closing the Gap mechanisms related to health care delivery.
The causes of inequitable health care are many. Western biomedical praxis differs from Indigenous foundational, holistic attention to the physical, emotional, mental and spiritual wellbeing of the person and the community.5 An article published in this issue of the MJA6 deals with the link between culture and language in improving communication in Indigenous health settings, a critical component of delivering cultural safety.
Integrating cultural safety in an active manner reconfigures health care to allow greater equity of realised access, rather than the assumption of full access, including procession to appropriate intervention.
As an example of the need to improve equity, a South Australian study found that Indigenous people presenting to emergency departments with acute coronary syndrome were half as likely as non-Indigenous patients to undergo angiography.7 More broadly, Indigenous people admitted to hospital are less likely to have a procedure for a condition than non-Indigenous people.8
Cardiovascular disease is the leading cause of death in Indigenous Australians.9 Cancer is the second biggest killer: the mortality rate for some cancers is three times higher for Indigenous than for non-Indigenous Australians.10 Clinical leaders in these two disease areas have identified the need for culturally safe health care to improve Indigenous health outcomes.
Cultural safety is an Indigenous-led model of care, with limited, but increasing, uptake, particularly in Australia, New Zealand and Canada. It acknowledges the barriers to clinical effectiveness arising from the inherent power imbalance between provider and patient,11 and moves to redress this dynamic by making the clinician’s cultural underpinning a critical focus for reflection.
Moreover, it invites practitioners to consider: “what do I bring to this encounter, what is going on for me?” Culturally safe care results where there is no inadvertent disempowering of the recipient, indeed where recipients are involved in the decision making and become part of a team effort to maximise the effectiveness of the care. The model pursues more effective practice through being aware of difference, decolonising, considering power relationships, implementing reflective practice, and by allowing the patient to determine what safety means.11
Along with an emphasis on provider praxis, cultural safety focuses on how institutional care is both envisaged and delivered.12 Literature on cultural safety in Australia is scant but growing.13 Where evidence is available, it identifies communication difficulties and racism as barriers not only to access but also to the receipt of indicated interventions or procedures.11
There is evidence of means to overcome these barriers. An Australian study undertaken across ten general practices tested the use of a cultural safety workshop, a health worker toolkit, and partnerships with mentors from Indigenous organisations and general practitioners.13 Cultural respect (significant improvements on cultural quotient score, along with Indigenous patient and cultural mentor rating), service (significant increase in Indigenous patients seen) and clinical measures (some significant increases in the recording of chronic disease factors) improved across the participating practices.
In addition, a 2010 study by Durey14 assessed the role of education, for both undergraduate students and health practitioners, in the delivery of culturally responsive health service, improving practice and reducing racism and disparities in health care between Indigenous and non-Indigenous Australians. The study found that cultural safety programs may lead to short term improvements to health practice, but that evidence of sustained change is more elusive because few programs have been subject to long term evaluation..
Newman and colleagues10 identified clinician reliance on stereotypical narratives of indigeneity in informing cancer care services. Redressing these taken-for-granted assumptions led to culturally engaged and more effective cancer care. In a similar manner, Ilton and colleagues15 addressed the importance of individual clinician cultural safety for optimising outcomes, noting that provider perceptions of Indigenous patient attributes may be biased toward conservative care.
The authors, however, went beyond the clinician–patient interaction to stress the outcome-enhancing power of change in the organisational and health setting. They proposed a management framework for acute coronary syndromes in Indigenous Australians.
This framework involved coordinated pathways of care, with roles for Indigenous cardiac coordinators and supported by clinical networks and Aboriginal liaison officers. It specified culturally appropriate warning information, appropriate treatment, individualised care plans, culturally appropriate tools within hospital education, inclusion of families and adequate follow-up.
Willis and colleagues16 also called for organisational change as an essential companion to individual practitioner development. Drawing on 12 studies involving continuous quality improvement (CQI) or CQI-like methods and short term interventions, they acknowledged evidence gaps, prescribing caution, and argued for such change to be undertaken in the service of long term controlled trials, as these would require 2–3 years to see any CQI-related changes.
Sjoberg and McDermott,17 however, noted the existence of barriers to change: the challenge (personal and professional) posed by Indigenous health and cultural safety training may not only lead to individual but also to institutional resistance.17 Dismantling individual resistance requires the development of a critical disposition — deemed central to professionalism and quality18 — but in a context of strengthened and legitimating accreditation specific to each discipline. The barriers thrown up by institutional resistance, manifesting as gatekeeping, marginalisation or underfunding, may require organisational change mandated by standards.