Decolonisation for health: A lifelong process of unlearning for Australian white nurse educators.

Indigenous nurse scholars across nations colonised by Europeans articulate the need for accomplices (as opposed to mere performative allies) to work alongside them and support their ongoing struggle for health equity and respect and to prioritise and promote culturally safe healthcare. Although cultural safety is now being mandated in nursing codes of practice as a strategy to address racism in healthcare, it is important that white nurse educators have a comprehensive understanding about cultural safety and the pedagogical skills needed to teach it to undergraduate nurses. We open this article with stories of our journeys as two white nurses in becoming accomplices and working alongside Indigenous Peoples, as patients and colleagues. Our lived experience of the inertia of healthcare and education organisations to address systemic and institutional resistance to the practice of cultural safety underpins the intention of this article. We understand that delivering this challenging and complex topic effectively and respectfully is best achieved when Indigenous and white educators work together at the cultural interface. Doing so requires commitment from white nurses and power holders within universities and healthcare institutions. A decolonising approach to nurse education at individual and institutional levels is fundamental to support and grow the work that needs to be done to reduce health inequity and increase cultural safety. White nurse accomplices can play an important role in teaching future nurses the importance of critical reflection and aiming to reduce power imbalances and racism within healthcare environments. Reducing power imbalances in healthcare environments and decolonising nursing practice is the strength of a cultural safety framework.

The emergence of cultural safety within kidney care for Indigenous Peoples in Australia.

Cultural safety is increasingly recognised as imperative to delivering accessible and acceptable healthcare for First Nations Peoples within Australia and in similar colonised countries. A literature review undertaken to inform the inaugural Caring for Australians with Renal Insufficiency (CARI) guidelines for clinically and culturally safe kidney care for Aboriginal and Torres Strait Islander peoples revealed a timeline of the emergence of culturally safe kidney care in Australia. Thirty years ago, kidney care literature was purely biomedically focused, with culture, family and community viewed as potential barriers to patient 'compliance' with treatment. The importance of culturally informed care was increasingly recognised in the mid-1990s, with cultural safety within kidney care specifically cited from 2014 onwards. The emergence timeline is discussed in this paper in relation to the five principles of cultural safety developed by Maori nurse Irihapeti Ramsden in Aotearoa/New Zealand. These principles are critical reflection, communication, minimising power differences, decolonisation and ensuring one does not demean or disempower. For the kidney care workforce, culturally safe care requires ongoing critical reflection, deep active listening skills, decolonising approaches and the eradication of institutional racism. Cultural safety is the key to truly working in partnership, increasing Indigenous Governance, respectful collaboration and redesigning kidney care.

Recommendations for culturally safe clinical kidney care for First Nations Australians: a guideline summary.

INTRODUCTION: First Nations Australians display remarkable strength and resilience despite the intergenerational impacts of ongoing colonisation. The continuing disadvantage is evident in the higher incidence, prevalence, morbidity and mortality of chronic kidney disease (CKD) among First Nations Australians. Nationwide community consultation (Kidney Health Australia, Yarning Kidneys, and Lowitja Institute, Catching Some Air) identified priority issues for guideline development. These guidelines uniquely prioritised the knowledge of the community, alongside relevant evidence using an adapted GRADE Evidence to Decision framework to develop specific recommendations for the management of CKD among First Nations Australians. MAIN RECOMMENDATIONS: These guidelines explicitly state that health systems have to measure, monitor and evaluate institutional racism and link it to cultural safety training, as well as increase community and family involvement in clinical care and equitable transport and accommodation. The guidelines recommend earlier CKD screening criteria (age ≥ 18 years) and referral to specialists services with earlier criteria of kidney function (eg, estimated glomerular filtration rate [eGFR], ≤ 45 mL/min/1.73 m2 , and a sustained decrease in eGFR, > 10 mL/min/1.73 m2 per year) compared with the general population. CHANGES IN MANAGEMENT AS RESULT OF THE GUIDELINES: Our recommendations prioritise health care service delivery changes to address institutional racism and ensure meaningful cultural safety training. Earlier detection of CKD and referral to nephrologists for First Nations Australians has been recommended to ensure timely implementation to preserve kidney function given the excess burden of disease. Finally, the importance of community with the recognition of involvement in all aspects and stages of treatment together with increased access to care on Country, particularly in rural and remote locations, including dialysis services.

Translating Cultural Safety to the UK.

Disproportional morbidity and mortality experienced by ethnic minorities in the UK have been highlighted by the COVID-19 pandemic. The 'Black Lives Matter' movement has exposed structural racism's contribution to these health inequities. 'Cultural Safety', an antiracist, decolonising and educational innovation originating in New Zealand, has been adopted in Australia. Cultural Safety aims to dismantle barriers faced by colonised Indigenous peoples in mainstream healthcare by addressing systemic racism.This paper explores what it means to be 'culturally safe'. The ways in which New Zealand and Australia are incorporating Cultural Safety into educating healthcare professionals and in day-to-day practice in medicine are highlighted. We consider the 'nuts and bolts' of translating Cultural Safety into the UK to reduce racism within healthcare. Listening to the voices of black, Asian and minority ethnic National Health Service (NHS) consumers, education in reflexivity, both personal and organisational within the NHS are key. By listening to Indigenous colonised peoples, the ex-Empire may find solutions to health inequity. A decolonising feedback loop is required; however, we should take care not to culturally appropriate this valuable reverse innovation.

Ambulatory care sensitive chronic conditions: what can we learn from patients about the role of primary health care in preventing admissions?

Developing and targeting interventions to reduce hospital admissions for ambulatory care sensitive (ACS) chronic conditions for older people is a key focus for improvement of the health system. To do this, an understanding of any modifiable factors that may contribute to such admissions is needed. To date, the literature on ACS admissions has rarely included the patient perspective. This qualitative study involved one-to-one telephone interviews with 24 patients aged ≥45 years who had had an unplanned admission for an ACS chronic condition to one of two participating regional hospitals between February and August 2015. Data were transcribed and analysed thematically. Most participants did not perceive their admission to be preventable, yet they described a series of interlinking factors, which may have contributed to their admission and which may offer potential points of leverage. Key interlinked themes interpreted were: 'support deficits', 'non-adherence to treatment' (including medication), 'mental health' and 'lack of awareness or understanding of condition'. Improving system-, clinician- and patient-level factors within a framework of appropriately resourced and supported comprehensive primary health care that is accessible, affordable, holistic, practical and evidence-based may contribute to improving patients' quality of life and to delaying or preventing hospital admission.

Admissions for chronic ambulatory care sensitive conditions - a useful measure of potentially preventable admission?

BACKGROUND: Potentially preventable hospital admission (an admission deemed to be potentially preventable given appropriate care in the community-based healthcare setting) has been a topic of international research attention for almost three decades. Recently this has been largely driven by the imperative to reduce ever-increasing unplanned hospital admissions. However, identifying potentially preventable admissions is difficult. As a result, the population level indicator of admissions for ambulatory care sensitive conditions (ACSCs) has been used as a proxy measure for potentially preventable admission. The adoption of this measure has become common, and in Australia, the rate of admissions for chronic ACSCs is now an important component of measuring health system performance and accountability, and is directly linked to funding. Admission for a chronic ACSC is also used to identify individuals for targeting of interventions to reduce preventable admissions. DISCUSSION: Hospital admission for chronic ACSCs is a population measure based on admission diagnoses, it therefore should not be used to identify individual preventable admissions. At present we are unable to determine individual admissions that are deemed to be preventable or, therefore, articulate the factors associated with admissions which are preventable. As we are currently unable to identify individual admissions that are preventable, little is understood about the underlying causes and factors contributing to preventable admissions. A means of assessing preventability of individual admissions is required. Only then can we explore the antecedents, and patient and clinician perspectives on preventable admissions. Until we have a clearer understanding of this, our capacity to inform policy and program development remains compromised.

Putting Indigenous Cultures and Indigenous Knowledges Front and Centre to Clinical Practice: Katherine Hospital Case Example.

The inclusion of Indigenous cultures, known as the cultural determinants of health, in healthcare policy and health professional education accreditation and registration requirements, is increasingly being recognised as imperative for improving the appalling health and well-being of Indigenous Australians. These inclusions are a strengths-based response to tackling the inequities in Indigenous Australians' health relative to the general population. However, conceptualising the cultural determinants of health in healthcare practice has its contextual challenges, and gaps in implementation evidence are apparent. In this paper, we provide a case example, namely the Katherine Hospital, of how healthcare services can implement the cultural determinants of health into clinical practice. However, to be effective, health professionals must concede that Australia's Indigenous peoples' knowledges involving cultural ways of being, knowing and doing must co-exist with western and biomedical knowledges of health practice. We use the Katherine Hospital ABC Radio National Background Briefing interview, which was mentioned by two research participants in a 2020 study, as an example of good practice that we can learn from. Additionally, the six Aboriginal and Torres Strait Islander Health actions contained in the 2nd Edition of the Australian National Safety and Quality Health Service Standards provide governance and accountability examples of how to enable Indigenous people's cultures and their knowledges in the provision of services. The role of non-Indigenous clinical allies and accomplices is imperative when embedding and enacting Indigenous Australians' cultures in service systems of health. When Indigenous Peoples access mainstream hospitals, deep self-reflection by allies and accomplices is necessary to enable safe, quality care, and treatment that is culturally safe and free from racism. Doing so can increase cultural responsiveness free of racism, thereby reducing the inherent power imbalances embedded within mainstream health services.

How feasible are lifestyle modification programs for disease prevention in general practice?

Vascular disease is a leading cause of death and disability. While it is preventable, little is known about the feasibility or acceptability of implementing interventions to prevent vascular disease in Australian primary health care. We conducted a cluster randomised controlled trial assessing prevention of vascular disease in patients aged 40-65 by providing a lifestyle modification program in general practice. Interviews with 13 general practices in the intervention arm of this trial examined their views on implementing the lifestyle modification program in general practice settings. Qualitative study, involving thematic analysis of semi-structured interviews with 11 general practitioners, four practice nurses and five allied health providers between October 2009 and April 2010. Providing brief lifestyle intervention fitted well with routine health-check consultations; however, acceptance and referral to the program was dependent on the level of facilitation provided by program coordinators. Respondents reported that patients engaged with the advice and strategies provided in the program, which helped them make lifestyle changes. Practice nurse involvement was important to sustaining implementation in general practice, while the lack of referral services for people at risk of developing vascular disease threatens maintenance of lifestyle changes as few respondents thought patients would continue lifestyle changes without long-term follow up. Lifestyle modification programs to prevent vascular disease are feasible in general practice but must be provided in a flexible format, such as being offered out of hours to facilitate uptake, with ongoing support and follow up to assist maintenance. The newly formed Medicare Locals may have an important role in facilitating lifestyle modification programs for this target group.

"Teaching in Circle" with student nurses contributes to experiential understanding of Cultural Safety.

Background: Cultural safety is mandated for Australian nursing practice and education. Cultural safety privileges the knowledge of the client, who determines whether healthcare is culturally safe. Understanding and learning cultural safety requires critical self-reflection to expose clinicians' assumptions, unconscious biases, beliefs and actions, and their impact on clients. More research is required on best-practice strategies on how students learn about cultural safety in nursing education. Experiential pedagogical methods may be one such strategy to promote understanding of principles that underpin safe environments.Objectives: To explore the influence of "Teaching in Circle" to enhance students' understanding of cultural safety within the classroom environment.Methods: Students in first-year undergraduate Bachelor of nursing units participated. Teachers facilitated tutorials using a respectful adaptation of "Teaching in Circle" methodology; it was underpinned by the principles of Yarning, an Aboriginal and Torres Strait Islander Peoples way of learning and communicating in groups. Students developed principles to guide the facilitation of a more culturally safe classroom, providing written feedback on the environment and their participation in the circle.Results: Student feedback was reflected in three themes: "Journey through unfamiliar territory"; "More personable way of learning and sharing" and "Relational engagement creates safety". Student perspectives resonated strongly with the principles of cultural safety or lack of within healthcare settings. The method disrupted normative classroom/learning environments and supported experiential learning about the principles of cultural safety.Conclusions: "Teaching in circle" provided an experiential means of enhancing first-year nursing students' understanding of the principles of cultural safety. This learning should be embedded in the nursing curriculum and on-going education to prepare nurses to provide culturally safer care to Aboriginal and Torres Strait Islander Peoples. The study supports similar research calling for innovative learner-focused, experiential methods for the development of the practice of cultural safety in Australian nursing education.Impact statement: Exploratory research project, "Teaching in Circle" with student nurses contributes to experiential understanding of cultural safety principles.

BlackLivesMatter in Healthcare: Racism and Implications for Health Inequity among Aboriginal and Torres Strait Islander Peoples in Australia.

Despite decades of evidence showing that institutional and interpersonal racism serve as significant barriers to accessible healthcare for Aboriginal and Torres Strait Islander Peoples, attempts to address this systemic problem still fall short. The social determinants of health are particularly poignant given the socio-political-economic history of invasion, colonisation, and subsequent entrenchment of racialised practices in the Australian healthcare landscape. Embedded within Euro-centric, bio-medical discourses, Western dominated healthcare processes can erase significant cultural and historical contexts and unwittingly reproduce unsafe practices. Put simply, if Black lives matter in healthcare, why do Aboriginal and Torres Strait Islander Peoples die younger and experience 'epidemic' levels of chronic diseases as compared to white Australians? To answer this, we utilise critical race perspectives to theorise this gap and to de-center whiteness as the normalised position of 'doing' healthcare. We draw on our diverse knowledges through a decolonised approach to promote a theoretical discussion that we contend can inform alternative ways of knowing, being, and doing in healthcare practice in Australia.

The perspectives of Aboriginal patients and their health care providers on improving the quality of hemodialysis services: a qualitative study.

Chronic kidney disease has a higher prevalence in Indigenous populations globally. The incidence of end-stage kidney disease in Australian Aboriginal people is eight times higher than non-Aboriginal Australians. Providing services to rural and remote Aboriginal people with chronic disease is challenging because of access and cultural differences. This study aims to describe and analyze the perspectives of Aboriginal patients' and health care providers' experience of renal services, to inform service improvement for rural Aboriginal hemodialysis patients. We conducted a thematic analysis of interviews with Aboriginal patients (n = 18) receiving hemodialysis in rural Australia and health care providers involved in their care (n = 29). An overarching theme of avoiding the "costly" crisis encompassed four subthemes: (1) Engaging patients earlier (prevent late diagnosis, slow disease progression); (2) flexible family-focused care (early engagement of family, flexibility to facilitate family and cultural obligations); (3) managing fear of mainstream services (originating in family dialysis experiences and previous racism when engaging with government organizations); (4) service provision shaped by culture (increased home dialysis, Aboriginal support and Aboriginal-led cultural education). Patients and health care providers believe service redesign is required to meet the needs of Aboriginal hemodialysis patients. Participants identified early screening and improving the relationship of Aboriginal people with health systems would reduce crisis entry to hemodialysis. These strategies alongside improving the cultural competence of staff would reduce patients' fear of mainstream services, decrease the current emotional and family costs of care, and increase efficiency of health expenditure on a challenging and increasingly unsustainable treatment system.

'Beats the alternative but it messes up your life': aboriginal people's experience of haemodialysis in rural Australia.

OBJECTIVES: Australian Aboriginal people have at least eight times the incidence of end-stage kidney disease, requiring dialysis, as the non-Aboriginal population. Provision of health services to rural Aboriginal people with renal disease is challenging due to barriers to access and cultural differences. We aimed to describe the experiences of Aboriginal people receiving haemodialysis in rural Australia, to inform strategies for improving renal services. DESIGN: A qualitative design incorporating: Indigenist research methodology and Community Based Participatory Research principles. In-depth interviews used a 'yarning' and storytelling approach. Thematic analysis was undertaken and verified by an Aboriginal Community Reference Group. SETTING: A health district in rural New South Wales, Australia. PARTICIPANTS: Snowball sampling recruited 18 Aboriginal haemodialysis recipients. RESULTS: Six themes emerged which described the patient journey: 'The biggest shock of me life,' expressed the shock of diagnosis and starting the dialysis; 'Beats the alternative but it messes up your life,' explained how positive attitudes to treatment develop; 'Family is everything', described the motivation and support to continue dialysis; 'If I had one of them nurses at home to help me', depicted acute hospital settings as culturally unsafe; 'Don't use them big jawbreakers', urged service providers to use simple language and cultural awareness; 'Stop 'em following us onto the machine', emphasised the desire for education for the younger generations about preventing kidney disease. An Aboriginal interpretation of this experience, linked to the analysis, was depicted in the form of an Aboriginal painting. CONCLUSIONS: Family enables Aboriginal people to endure haemodialysis. Patients believe that priorities for improving services include family-centred and culturally accommodating healthcare systems; and improving access to early screening of kidney disease. Inclusion of Aboriginal patients in cultural education for renal staff is recommended. Providing opportunities for patients to educate young Aboriginal people about kidney disease prevention may be highly effective and empowering.

Service providers' perspectives, attitudes and beliefs on health services delivery for Aboriginal people receiving haemodialysis in rural Australia: a qualitative study.

OBJECTIVE: Providing services to rural dwelling minority cultural groups with serious chronic disease is challenging due to access to care and cultural differences. This study aimed to describe service providers' perspectives on health services delivery for Aboriginal people receiving haemodialysis for end-stage kidney disease in rural Australia. DESIGN: Semistructured interviews, thematic analysis SETTING: A health district in rural New South Wales, Australia PARTICIPANTS: Using purposive sampling, 29 renal and allied service providers were recruited, including nephrologists, renal nurses, community nurses, Aboriginal health workers, social workers and managers. Six were Aboriginal and 23 non-Aboriginal. RESULTS: Improving cultural understanding within the healthcare system was central to five themes identified: rigidity of service design (outreach, inevitable home treatment failures, pressure of system overload, limited efficacy of cultural awareness training and conflicting priorities in acute care); responding to social complexities (respecting but challenged by family obligations, assumptions about socioeconomic status and individualised care); promoting empowerment, trust and rapport (bridging gaps in cultural understanding, acknowledging the relationship between land, people and environment, and being time poor); distress at late diagnosis (lost opportunities and prioritise prevention); and contending with discrimination and racism (inherent judgement of lifestyle choices, inadequate cultural awareness, pervasive multilevel institutionalised racism and managing patient distrust). CONCLUSIONS: Service providers believe current services are not designed to address cultural needs and Aboriginality, and that caring for Aboriginal patients receiving haemodialysis should be family focused and culturally safer. An Aboriginal-specific predialysis pathway, building staff cultural awareness and enhancing cultural safety within hospitals are the measures recommended. Increasing patient support for home haemodialysis may improve health and the quality of care outcomes.