Bridging cultures in palliative care: A qualitative study of the care of Indigenous Australians with advanced illness.

BACKGROUND: Lack of access, late engagement and limited referral for palliative care remain critical issues in supporting Indigenous Australians with life limiting illness. AIM: To explore the experiences and perspectives of Indigenous and non-Indigenous health professionals regarding the provision of palliative care for Indigenous people with advanced disease. DESIGN: Qualitative study involving semi-structured focus groups/interviews with analysis following an inductive thematic approach. SETTING/PARTICIPANTS: A purposive sample (n = 54) of medical, nursing, allied health and Indigenous Hospital Liaison Officers engaged in caring for Indigenous patients at a metropolitan teaching hospital in Australia. RESULTS: Four overarching themes were identified regarding provision of palliative care for Indigenous patients. These were (1) the intersection of cultures - Indigenous peoples, health and palliative care, (2) bridging the cultural divide: the integral role of Indigenous Hospital Liaison Officers, (3) health professionals devolve their responsibility to provide culturally appropriate care and (4) building towards a more holistic, culturally aware provision of palliative care. CONCLUSIONS: For many Indigenous people, the health system may be experienced as inflexible, narrowly focused and even prejudiced and traumatising. For Indigenous patients at the end of life, these challenges are heightened. The Indigenous Hospital Liaison Officers, working at the intersections of these two cultures, are key to negotiating such challenges as they seek opportunities to facilitate communication and understanding between firmly held cultural needs.

Characteristics of First Nations patients who take their own leave from an inner-city emergency department, 2016-2020.

OBJECTIVE: Using a strength-based framework, we aimed to describe and compare First Nations patients who completed care in an ED to those who took their own leave. METHODS: Routinely collected adult patient data from a metropolitan ED collected over a 5-year period were analysed. RESULTS: A total of 6446 presentations of First Nations patients occurred from 2016 to 2020, constituting 3% of ED presentations. Of these, 5589 (87%) patients waited to be seen and 857 (13%) took their own leave. Among patients who took their own leave, 624 (73%) left not seen and 233 (27%) left at own risk after starting treatment. Patients who were assigned a triage category of 4-5 were significantly more likely to take their own leave (adjusted odds ratio [OR] 3.17, 95% confidence interval [CI] 2.67-3.77, P < 0.001). Patients were significantly less likely to take their own leave if they were >60 years (adjusted OR 0.69, 95% CI 1.01-1.36, P = 0.014) and had private health insurance (adjusted OR 0.61, 95% CI 0.45-0.84, P < 0.001). Patients were more likely to leave if they were women (adjusted OR 1.17, 95% CI 1.01-1.36, P = 0.04), had an unknown housing status (adjusted OR 1.76, 95% CI 1.44-2.15, P < 0.001), were homeless (adjusted OR 1.50, 95% CI 1.22-1.93, P < 0.001) or had a safety alert (adjusted OR 1.60, 95% CI 1.35-1.90, P < 0.001). CONCLUSION: A lower triage category is a strong predictor of First Nations patients taking their own leave. It has been documented that First Nations patients are under-triaged. One proposed intervention in the metropolitan setting is to introduce practices which expediate the care of First Nations patients. Further qualitative studies with First Nations patients should be undertaken to determine successful approaches to create equitable access to emergency healthcare for this population.

Laying the foundations of community engagement in Aboriginal health research: establishing a community reference group and terms of reference in a novel research field.

BACKGROUND: Community engagement or community involvement in Aboriginal health research is a process that involves partnering, collaborating and involving Aboriginal and Torres Strait Islander people or potential research participants to empower them to have a say in how research with Aboriginal communities is conducted. In the context of Aboriginal health, this is particularly important so that researchers can respond to the priorities of the community under study and conduct research in a way that is respectful of Aboriginal cultural values and beliefs. One approach to incorporating the principals of community engagement and to ensure cultural oversight and guidance to projects is to engage a community reference group. The aim of this study was to describe the process of establishing an Aboriginal community reference group and terms of reference. The community reference group was established to guide the research activities of a newly formed research collaboration aiming to to develop osteoarthritis care that meets the needs of Aboriginal and Torres Strait Islander people in Australia. METHODS: Adopting a Participatory Action Research approach, this two-phase study was conducted in Victoria, Australia. In phase one, semi-structured research yarns (a cultural form of conversation used as a data gathering tool) were conducted collaboratively by Aboriginal and non-Aboriginal co-investigators to explore Aboriginal health stakeholder perspectives on establishing a community reference group and terms of reference. In phase two, recommendations in phase one were identified to invite members to participate in the community reference group and to ratify the terms of reference through a focus group. Data were analyzed using a framework analysis approach. RESULTS: Thirteen people (eight female, four male) participated in phase one. Participants represented diverse professional backgrounds including physiotherapy, nursing, general practice, health services management, hospital liaison, cultural safety education, health research and the arts. Three themes were identified in phase one; Recruitment and Representation (trust and relationships, in-house call-outs, broad-spectrum expertise and Aboriginal majority); Purpose (community engagement, research steering, knowledge dissemination and advocacy) and; Function and Logistics (frequency and format of meetings, size of group, roles and responsibilities, authority, communication and dissemination). In phase two, six Aboriginal people were invited to become members of the community reference group who recommended changes which were incorporated into the seven domains of the terms of reference. CONCLUSION: The findings of this study are captured in a 10-step framework which describes practical strategies for establishing a community reference group and terms of reference in Aboriginal health research.

Community engagement or community involvement in Aboriginal health research is a process that involves partnering with Aboriginal and Torres Strait Islander people or potential research participants to empower them to have a say in how research with Aboriginal communities is carried out. In the context of Aboriginal health, this is particularly important so that researchers can respond to the priorities of the community and conduct research in a way that respectful of Aboriginal cultural values and beliefs. One approach to community engagement in research is to form a community reference group to provide input to the research project. Although using a community reference group is considered to be an effective way to involve community members in research, often there are practical challenges in setting up and sustaining such a group. In this paper, we set out to describe an approach used to set up a community reference group for a new Aboriginal health research project exploring joint pain in Aboriginal and Torres Strait Islander people. This involved interviewing 13 health professionals and researchers (12 who identified as Aboriginal and one who identified as Aboriginal and Torres Strait Islander) about how to best go about setting up a community reference group. We used recommendations from these participants to inform who we approached to be members of the group and how the group would function. In describing the process we used to establish a community reference group, we were able to design a 10-step practical guide which may help other research groups who are looking to conduct new, ethical Aboriginal health research projects.

Development, implementation, and evaluation of a trauma-informed simulation-based training program for graduate nurses: A single arm feasibility and pilot study.

BACKGROUND: The chance of hospital staff encountering a patient with a trauma history is high. The way health services are offered and carried out are important when engaging with people who have experienced trauma. Implementing training in trauma-informed care (TIC) is part of a cultural change of benefit to both patients and staff. Simulation-based training is a well-accepted method to reduce staff fear and anxiety when working with individuals in distress and to address issues relating to bias and stigma. OBJECTIVES: To provide simulation-based TIC training to graduate nurses. DESIGN: A three-phase process was undertaken to i) create the intervention, ii) determine feasibility, and iii) evaluate the developed training. SETTING: A 600-bed inner-city tertiary hospital in Melbourne, Victoria. PARTICIPANTS: Graduate nurses undertaking their first year of employment (n = 23). METHODS: The content of the training was created using evidence derived from a literature review, a scoping study of available resources, and expert consensus. A pre/post-test within-groups design to assess the safety, acceptability, and effectiveness of the training was undertaken. RESULTS: The Trauma Informed-Simulation Based Training (TI-SBT) aims to increase TIC knowledge and promote TIC behaviours. It is delivered face-to-face over one day and encompasses an education component followed by three immersive patient simulations using professional actors. Analysis found significant improvement in TIC knowledge (p ≤ 0.001, 95% CI = -3.53, -0.47) and behaviours (p = 0.013, 95% CI = -8.88, -5.03). No significant differences were found in measures of anxiety and confidence. Satisfaction with all aspects of the training was high. Qualitatively, participants provided concrete examples of changes to their practice to facilitate TIC. CONCLUSIONS: The developed and novel TI-SBT is a feasible (safe, acceptable, and effective) way of introducing TIC to graduate nurses. These findings provide strong evidence to support a more rigorous evaluation of the training by randomised controlled trial. The TI-SBT has the capacity to not only improve patient care but the experience of hospital staff.

Working towards equity: An example of an emergency department project for Aboriginal and Torres Strait Islander health and cultural safety.

The ED at St Vincent's Hospital Melbourne aims to provide excellent emergency care and cultural safety for Aboriginal and Torres Strait Islander peoples. High rates of people who 'Left Not Seen' and some negative experiences of care led us to improve our performance in this area. Collective desire and strong executive support generated the ED Indigenous Health Equity Working Group (IHEWG) project. This was co-led by both the ED and the Aboriginal Health Unit (AHU). A strengths-based participatory methodology and fortnightly virtual meetings were established to generate ideas for short- and long-term reforms. Initial outcomes have included a focus on cultural safety and trauma-informed care education. Further projects included improving identification processes, creating a welcoming waiting-room environment and fostering strong relationships between the ED and AHU. We have begun our ED journey towards equity and excellent care for Aboriginal and Torres Strait Islander people, hoping this collaborative model will enable transformative change.

"The support has been brilliant": experiences of Aboriginal and Torres Strait Islander patients attending two high performing cancer services.

BACKGROUND: Improving health outcomes for Indigenous people by providing person-centred, culturally safe care is a crucial challenge for the health sector, both in Australia and internationally. Many cancer providers and support services are committed to providing high quality care, yet struggle with providing accessible, culturally safe cancer care to Indigenous Australians. Two Australian cancer services, one urban and one regional, were identified as particularly focused on providing culturally safe cancer care for Indigenous cancer patients and their families. The article explores the experiences of Indigenous cancer patients and their families within the cancer services and ascertains how their experiences of care matches with the cancer services' strategies to improve care. METHODS: Services were identified as part of a national study designed to identify and assess innovative services for Indigenous cancer patients and their families. Case studies were conducted with a small number of identified services. In-depth interviews were conducted with Indigenous people affected by cancer and hospital staff. The interviews from two services, which stood out as particularly high performing, were analysed through the lens of the patient experience. RESULTS: Eight Indigenous people affected by cancer and 23 hospital staff (Indigenous and non-Indigenous) were interviewed. Three experiences were shared by the majority of Indigenous cancer patients and family members interviewed in this study: a positive experience while receiving treatment at the cancer service; a challenging time between receiving diagnosis and reaching the cancer centre; and the importance of family support, while acknowledging the burden on family and carers. CONCLUSIONS: This article is significant because it demonstrates that with a culturally appropriate and person-centred approach, involving patients, family members, Indigenous and non-Indigenous staff, it is possible for Indigenous people to have positive experiences of cancer care in mainstream, tertiary health services. If we are to improve health outcomes for Indigenous people it is vital more cancer services and hospitals follow the lead of these two services and make a sustained and ongoing commitment to strengthening the cultural safety of their service.

Review article: Implicit bias towards Aboriginal and Torres Strait Islander patients within Australian emergency departments.

Aboriginal and Torres Strait Islander peoples continue to suffer adverse experiences in healthcare, with inequitable care prevalent in emergency settings. Individual, institutional and systemic factors play a significant part in these persisting healthcare disparities, with biases remaining entrenched in healthcare institutions. This includes implicit racial bias which can result in stereotyping of racial minorities and premature diagnostic closure. Furthermore, it may contribute to distrust of medical professionals resulting in higher rates of leave events and hinder racial minorities from seeking care or following treatment recommendations. The aim of this review is to analyse the effect of implicit bias on patient outcomes in the ED in international literature and explore how these studies correlate to an Australian context.

"We're very much part of the team here": A culture of respect for Indigenous health workforce transforms Indigenous health care.

BACKGROUND: Improving health outcomes for Indigenous people by strengthening the cultural safety of care is a vital challenge for the health sector, both in Australia and internationally. Although Indigenous people have long requested to have Indigenous practitioners involved in their health care, many health services report difficulties with recruiting and retaining Indigenous staff. This article describes Indigenous workforce policies and strategies from two Australian health services, as well as cancer-service specific strategies. METHODS: Services were identified as part of a national study designed to identify and assess innovative services for Indigenous cancer patients and their families. In-depth interviews were conducted in a small number of identified services. The interviews from two services, which stood out as particularly high performing, were analysed through the lens of Indigenous health workforce. RESULTS: Twenty-four hospital staff (Indigenous and non-Indigenous), five Indigenous people with cancer and three family members shared their views and experiences. Eight themes were identified from the way that the two services supported their Indigenous workforce: strong executive leadership, a proactive employment strategy, the Indigenous Health Unit, the Indigenous Liaison Officer, multidisciplinary team inclusion, professional development, work environment and a culture of respect. Participants reported two positive outcomes resulting from the active implementation of the eight workforce themes: 'Improved Indigenous patient outcomes' and 'Improved staff outcomes'. CONCLUSIONS: These two cancer services and their affiliated hospitals show how positive patient outcomes and a strong Indigenous health workforce can be achieved when a health service has strong leadership, commits to an inclusive and enabling culture, facilitates two-way learning and develops specific support structures appropriate for Indigenous staff. It is hoped that the strategies captured in this study will be used by health services and cancer services to inform their own policies and programs to support building their Indigenous workforce.

The study protocol for a randomized controlled trial of a family-centred tobacco control program about environmental tobacco smoke (ETS) to reduce respiratory illness in Indigenous infants.

BACKGROUND: Acute respiratory illness (ARI) is the most common cause of acute presentations and hospitalisations of young Indigenous children in Australia and New Zealand (NZ). Environmental tobacco smoke (ETS) from household smoking is a significant and preventable contributor to childhood ARI. This paper describes the protocol for a study which aims to test the efficacy of a family-centred tobacco control program about ETS to improve the respiratory health of Indigenous infants in Australia and New Zealand. For the purpose of this paper 'Indigenous' refers to Australia's Aboriginal and Torres Strait Islander peoples when referring to Australian Indigenous populations. In New Zealand, the term 'Indigenous' refers to Maori. METHODS/DESIGN: This study will be a parallel, randomized, controlled trial. Participants will be Indigenous women and their infants, half of whom will be randomly allocated to an 'intervention' group, who will receive the tobacco control program over three home visits in the first three months of the infant's life and half to a control group receiving 'usual care' (i.e. they will not receive the tobacco control program). Indigenous health workers will deliver the intervention, the goal of which is to reduce or eliminate infant exposure to ETS. Data collection will occur at baseline (shortly after birth) and when the infant is four months and one year of age. The primary outcome is a doctor-diagnosed, documented case of respiratory illness in participating infants. DISCUSSION: Interventions aimed at reducing exposure of Indigenous children to ETS have the potential for significant benefits for Indigenous communities. There is currently a dearth of evidence for the effect of tobacco control interventions to reduce children's exposure to ETS among Indigenous populations. This study will provide high-quality evidence of the efficacy of a family-centred tobacco control program on ETS to reduce respiratory illness. Outcomes of our study will be important and significant for Indigenous tobacco control in Australia and New Zealand and prevention of respiratory illness in children.

How do trends in smoking prevalence among Indigenous and non-Indigenous Australian secondary students between 1996 and 2005 compare?

OBJECTIVE: To compare trends in smoking prevalence between 1996 and 2005 among Indigenous and non-Indigenous secondary students across Australia. METHODS: Representative random samples of secondary students aged 12-17 years completed self-report anonymous surveys. Questionnaires assessed any cigarette smoking in lifetime, and smoking in past month, week and on at least three of the previous seven days. Intention to smoke in the next 12 months was assessed on a 7-point scale. Students self-identified as being of Aboriginal or Torres Strait Islander descent. RESULTS: Three to four per cent of students identified as being Indigenous at each survey. Smoking was more common among Indigenous than non-Indigenous students. Between 1996 and 2005, the proportion of smoking declined among both Indigenous and non-Indigenous students. However, among 12-15 year olds, the rate of decline was different for the two groups. Among non-Indigenous students in this age group, prevalence decreased steadily between 1996 and 2005. Among Indigenous students, the decrease mainly occurred between 1999 and 2002. Smoking intention was higher for Indigenous than non-Indigenous students. The mean intention decreased between 1996 and 2005 among both student groups. CONCLUSIONS: Smoking prevalence decreased among both Indigenous and non-Indigenous students between 1996 and 2005. IMPLICATIONS: Reductions in Indigenous students' tobacco use and intentions coincided with a period of increased tobacco control activity, suggesting that these activities may positively influence smoking behaviours.