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Keywords:

  • Aboriginal Australian;
  • cultural safety;
  • education;
  • forensic mental health care

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Survey Findings
  6. Interview Findings
  7. Discussion and Conclusion
  8. Acknowledgements
  9. References

Mental illnesses constitute a major burden of disease in Aboriginal Australians and Torres Strait Islanders (hereafter Aboriginal Australians), who are also overrepresented in the prison system. A legacy of colonization compounds such prevalence, and is further exacerbated by the persistence of racial discrimination and insensitivity across many sectors, including health. This research completed in a Western Australian forensic mental health setting identifies non-Aboriginal health professionals' support needs to deliver high-quality, culturally-safe care to Aboriginal patients. Data were collected from health professionals using an online survey and 10 semistructured interviews. Survey and interview results found that ongoing education was needed for staff to provide culturally-safe care, where Aboriginal knowledge, beliefs, and values were respected. The findings also support previous research linking Aboriginal health providers to improved health outcomes for Aboriginal patients. In a colonized country, such as Australia, education programmes that critically reflect on power relations privileging white Anglo-Australian cultural dominance and subjugating Aboriginal knowledge, beliefs, and values are important to identify factors promoting or compromising the care of Aboriginal patients and developing a deeper understanding of ‘cultural safety’ and its clinical application. Organizational commitment is needed to translate the findings to support non-Aboriginal health professionals deliver high-quality care to Aboriginal patients that is respectful of cultural differences.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Survey Findings
  6. Interview Findings
  7. Discussion and Conclusion
  8. Acknowledgements
  9. References

Prisoners are often from the most vulnerable social groups, and many experience further isolation and stigmatization as a result of mental illness (Gilles et al. 2008). In many countries, including the USA, UK, Canada, and Australia, structural changes from the 1950s to the 1980s led to deinstitutionalization, where the focus of care for people with mental illness shifted from institutions to community-based services (Lamb & Weinberger 2005). In Australia, psychiatric beds were drastically cut from 30,000 in the early 1960s to 8000 in 2006, despite the population doubling in that time (White & Whiteford 2006). Failed social policies and inadequate community-based mental health services resulted in disproportional representation and management of people with mental illness in the criminal justice system from actions resulting from their mental illness (Doessel et al. 2005; Lamb & Weinberger 2005). Prisons became ‘the only places to give the equivalent of good inpatient treatment’ (Lamb & Weinberger 2005, p. 532).

Australia recently allocated substantial funds to improve the mental health of the Australian community and placed emphasis on the importance of mental health education, social inclusion, recovery, health promotion, early intervention, and improving intersectoral collaboration and service delivery (Australian Government 2011). The Fourth National Mental Health Plan 2009–2014 (Department of Health and Ageing 2009) focuses on recovery and includes addressing social determinants of health; for example, linking mental health services with housing programmes and improving the quality of mental health care where services are held accountable and progress is measured and reported (Department of Health and Ageing 2009).

Another key policy focus is improving Aboriginal Australians' and Torres Strait Islanders (hereafter Aboriginal Australians') health (Prime Minister's Report 2013), where mental illnesses constitute a major burden of disease. Aboriginal Australians are twice as likely as other Australians to report high/very high levels of psychological distress (Pink & Allbon 2008). Such prevalence is compounded by a legacy of colonization and ongoing racial discrimination, oppression, abuse, and insensitivity across several sectors, including education, health, housing, and employment (Browne & Varcoe 2006; Paradies et al. 2008). The ubiquitous legacy of dispossession and disempowerment of Indigenous peoples also occurred in Canada, USA, and Aotearoa/New Zealand, and is reflected in their overrepresentation in prisons (Feldstein et al. 2005; Roberts & Melchers 2003).

Prison populations are often drawn from areas of sociodemographic disadvantage, where education is limited, unemployment high, and abuse and neglect prevalent (Kariminia et al. 2006). Indigeneity and discrimination can increase disadvantage and exacerbate an already vulnerable status, where mental and physical health is poor (Larson et al. 2007). A recent study on an urban Aboriginal population in South Australia indicated that 93% of participants experienced racism regularly and these experiences were negatively associated with mental health (Ziersch et al. 2011). Therefore, it is important to ensure Aboriginal patients receive high-quality, non-discriminatory care to optimize health and decrease the gap between the health outcomes of Aboriginal and non-Aboriginal Australians. While improvements in Aboriginal health require interventions at the societal and primary health-care levels, the delivery of culturally-safe care during hospitalization is also a priority.

In Western Australia, forensic mental health services are located within the health system, but patients move regularly between the health and criminal justice systems. The State Forensic Mental Health Service (SFMHS) comprises a secure 30-bed inpatient unit and an eight-bed open-ward facility. Community forensic services offer court liaison and community assertive case management programmes. Approximately 240 patients annually are admitted to the service, and Aboriginal Australians make up approximately 30% of admissions, despite constituting only 3.1% of the Western Australian population (ABS 2012). The SFMHS provides comprehensive assessment and treatment services to offenders and alleged offenders who have mental illnesses, and most present with psychotic illnesses and other comorbidities, such as depression and anxiety (ABS 2011). Patient categories for admission to the service include: (i) hospital orders under the Western Australian Criminal Law (Mentally Impaired Accused) Act 1996, patients can be detained by order of a magistrate for up to 7 days for psychiatric assessment; (ii) prisoners who are transferred under Section 83, Western Australian Prisons Act 1981 for treatment of their mental illness; and (iii) persons found not guilty of a crime due to unsoundness of mind or not being fit to plead. While all mental health professionals working in acute settings have conflicting custodial, therapeutic, and caring roles due to involuntary admissions, these roles are often exacerbated in a forensic mental health setting. This occurs due to the close interface between the criminal justice system and the health system (Cashin et al. 2010) mandated by legislative requirements; for example, under the Western Australian Criminal Law (Mentally Impaired Accused) Act 1996.

Kleinman, Eisenberg and Good's (1978, p. 252) seminal work highlighted how illness is ‘culturally shaped’ and how culture impacts on illness and treatment. With such high numbers of Aboriginal patients admitted to the service, staff face considerable challenges to deliver care that is sensitive and respectful of cultural differences. However, research in other areas of the health-care system has shown that health professionals often lack the required knowledge, skills, time, and resources to engage with this group effectively (Durey & Thompson 2012).

While national policy initiatives around working with Aboriginal patients highlight the importance of respecting diversity and including Aboriginal cultural values in care delivery, the challenge at the service level is to avoid tokenism and evaluate the effectiveness of initiatives to improvements in Aboriginal mental health outcomes (Durey 2010). The Australian Medical Association (2011) advocates Aboriginal cultural values and perspectives as best practice in service delivery to Aboriginal patients, and different cultural frameworks are now emerging to assess mental illnesses in Aboriginal people (see Schlesinger et al. 2007; Smith et al. 2009; Thomas et al. 2010). The present study adds to the understanding of the needs of non-Aboriginal health professionals by identifying their learning and support needs to deliver high-quality, culturally-safe care to Aboriginal patients in a forensic mental health setting.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Survey Findings
  6. Interview Findings
  7. Discussion and Conclusion
  8. Acknowledgements
  9. References

Ethics approval was granted by Curtin University, the Western Australian Aboriginal Health Ethics Committee, and the North Metropolitan Area Health Service – Mental Health.

Data collection

Quantitative and qualitative methods were used to gather data from non-Aboriginal health professionals at the service. First, all health professionals (n = 90) were invited to complete an online survey delivered through Survey Monkey (SurveyMonkey 2012). The survey collected demographic data and responses to questions about: (i) factors that helped or compromised their care of Aboriginal patients; (ii) educational, training and support needs; and (iii) factors that strengthened relationships with Aboriginal patients and their families. Second, they were invited to participate in a semistructured interview to allow researchers to gain a deeper understanding of issues in this area, and 10 staff agreed to be interviewed. Following written consent, the semistructured interviews were conducted and audio-recorded by one researcher (AD). Interviews were then transcribed by the researcher and imported into NVIVO (QSR International, Melbourne, Victoria, Australia), a computer software package to help organize and manage qualitative data, with information about participants de-identified to ensure confidentiality.

Data analysis

The survey responses were analysed in the Survey Monkey database using descriptive statistics (frequencies) for all variables. Key themes from the interview responses were identified from a line-by-line analysis and interrogated and extended by comparing responses for similarities and differences between participants and identifying any emerging patterns. Data were revisited, discussed between two researchers (DW and AD), reviewed, and subthemes identified and linked to emerging key themes. This iterative process allowed findings and interpretations to be revised, modified, refined, and summarized to ensure consistency and quality until consensus was obtained between the researchers. The findings were then interrogated with evidence from the literature (Bazeley 2007).

Survey Findings

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Survey Findings
  6. Interview Findings
  7. Discussion and Conclusion
  8. Acknowledgements
  9. References

Fifty-one staff from medical, nursing, and allied health backgrounds participated in this survey giving a response rate of 56.6% (n = 51). The majority were female, nurses, and currently employed full time at the service. Participants' ages ranged from 31 to 50 years, and work experience in forensic mental health varied between 1 and 30 years, with the highest proportion of staff being in the service from 1 to 5 years.

Factors influencing high-quality care to Aboriginal patients

The participants believed that several factors influenced good quality care to Aboriginal patients, including knowing about Australian Aboriginal culture (72% of participants), Aboriginal history and colonization (51%), and education and training to work with Aboriginal patients (51%). Sixty-six per cent considered self-awareness and good reflective skills to also be important.

The participants also identified service factors compromising high-quality care, including a lack of resources to promote the well-being of Aboriginal people (50%), insufficient time to meet individual patient needs (50%), inadequate staffing levels (50%), and the need to improve liaison with Aboriginal health/support services (34%). Forty per cent of participants thought their lack of knowledge of Aboriginal culture undermined care.

Improving care to Aboriginal patients

Key factors improving the quality of care delivered to Aboriginal patients included ongoing education and training in cultural competence and sensitivity (76% of participants), employing Aboriginal staff at the service (63%), and incorporating culturally-sensitive and secure assessment tools (59%). Cultural issues were also identified, including the need for more collaboration with Aboriginal community members (51%), increasing awareness of cultural protocols when working with Aboriginal people (49%), and a willingness to engage with Aboriginal culture and practices (47%).

Education training and support for staff working with Aboriginal patients

When asked about the type of training required, the participants wanted more education on Aboriginal perceptions of mental health and illness (65%), culturally-appropriate and sensitive assessment of Aboriginal patients (47%), and ways to reduce discrimination against Aboriginal people (45%). Only one participant thought the current education and training programme was adequate.

Strengthening relationships with Aboriginal patients and their families

The participants identified three key factors to strengthen relationships with Aboriginal patients and their families: culturally-appropriate communication between staff and patients (55%), more communication between health providers and patients' families and community (51%), and employing full-time Aboriginal health workers/support staff at the service (40%).

Interview Findings

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Survey Findings
  6. Interview Findings
  7. Discussion and Conclusion
  8. Acknowledgements
  9. References

Key themes identified from semistructured interview responses (identified as P1–P10) were better education and training in culturally-safe care for Aboriginal patients, embedding Aboriginal health workers/support staff at the service, negotiating the intersection between health and secure care, and improving relationships with Aboriginal people.

Culturally-safe care

Barriers to engagement included service constraints on delivering care in a forensic mental health setting, such as limitations of current training programmes to educate staff to work with Aboriginal patients and their families in ways that are sensitive and respectful of cultural differences. Since 2009, new staff are required to watch an orientation DVD as part of their induction to the service, including a section on supporting Aboriginal patients. However, perhaps due to the volume of information provided during orientation, no participants commented on the Aboriginal component covered in the DVD, with one participant admitting: ‘I have had no education, no training, no tips’ (P2). It was also suggested that such training programmes should be mandatory for all health professionals:

I don't think there is anything in that orientation that mentions anything to do with Aboriginals, even the mandatory training we have (at orientation) … and I think it should be! You have to do it. (P7)

The need for more education and training was supported by most participants who wanted ongoing Aboriginal cultural education to better translate the concepts presented into the practice domain:

It needs to be embedded, and if you look at our patient populations, we have a very high proportion of Aboriginal people who come through here, and that needs to be recognized by the service and followed through. (P4)

Including sociohistorical factors in ongoing education and training was also important for health professionals to understand their impact on Aboriginal mental health and contextualize patients' responses to assessment and treatment:

You can only be invited into someone's personal space and you can only do good when you are properly invited in, and Aboriginal people have particular concerns about that. They will keep you out; historical trauma and those things (where) they don't trust white people, the Western world. (P8)

Embedding Aboriginal health workers/support staff

Arrangements are in place for Aboriginal health workers/support staff from the state Aboriginal mental health services to visit and work with Aboriginal patients at the SFMHS on a case-by-case basis. However, most participants considered that embedding Aboriginal health workers/support staff at the service was integral to patients feeling culturally safe. They would also assist health professionals to provide assessment and care that was respectful of Aboriginal cultural knowledge, including interpreting symptoms of mental illness in a culturally-informed way:

Just talking to an Aboriginal person helps to sort out what is psychosis, delusion, hallucination from what is being sung, sorry business, to appropriate grieving. Obviously there is education I can have to help that, but I think the ultimate way is to have the Aboriginal health worker alongside you, able to filter. (P7)

However, participants felt that the highly-valued and specialized role of Aboriginal health workers/support staff needed more institutional recognition and support:

What you have to do is reflect support systems for Aboriginal people into your management structure, and that is where most people fall down; they employ nominal (Aboriginal) staff who leave after 6 months. … There needs to be a support structure. (P1)

Health and secure care

As previously stated, forensic mental health professionals work in an environment where the balance between the therapeutic role and ensuring security and safety is often exacerbated when compared to other acute inpatient settings. One of the issues posed by providing care in this setting was the limited amount of time patients spent outdoors each day and the effect this might have on Aboriginal patients' well-being:

(Patients) are locked inside most of the day … unless they have ground (or courtyard) access. Now, you have to question how therapeutic that would be for an Aboriginal person who would rather be outside than inside. (P3)

Participants were aware not just of the security needs in this environment:

Part of it is about safety, but also, it is about showing respect to people. (P2)

This theme of respect was reiterated in another context:

All the phases of an assessment process need to be culturally appropriate; coming onto this land here, it needs to be done properly … and have a culture in here with appropriately-trained staff who are sensitive, understanding, and as culturally safe, secure and appropriate as can be for everybody who comes in here. (P8)

Building relationships

In managing the restrictions placed upon them in such environments, participants adopted a more holistic perspective in their interactions with Aboriginal patients. This included being open to other ways of communicating that were respectful of cultural differences; acknowledging the sociohistorical context, including the legacy of colonization of Aboriginal people; and creating a space to establish a relationship:

I think one of the problems people have is talking with Aboriginal people, because you may need to sit down for 10 min and they can quite easily be silent, not say much, or they might want to yarn, tell you a story which goes on 10–15 min and you are thinking ‘What is the point of this?’. To engage is a much slower process. Aboriginal people are bound to be suspicious of us because we are the people who oppressed them. I keep my cards quite close to my chest until I suss people out and that is what they do. Makes sense, a totally logical way to behave, but I think us white people find that quite uncomfortable – silence and not getting to the point straight away. (P1)

It seemed that non-Aboriginal participants wanted to engage effectively with Aboriginal patients, and despite the pressures in the work environment, they took time to build relationships and find points of connection that reflected commonalities and created opportunities to establish relationships:

You can sit down, have a chat, go and play ball out in the yard, watch football, point out your favourite footy players. Just trying to find that common ground where you can build that trust and get to ‘So what's going on? How come you ended up here?’. They might say it's none of your business or they might come up and start talking to you. (P4)

It became clear that participants wanted to engage in ways that moved beyond tokenism:

It's understanding as deeply as possible and understanding the meta issues as well, so not just the mind (of an Aboriginal person), but also what the Aboriginal people are going through, to put it into context, to have understanding and dialogue with Aboriginal people. (P8)

Participants wanted to be more sensitive to the Aboriginal patient's experience and culture:

I like the landscape thing because it is an Aboriginal metaphor where you get into their landscape and walk on their internal world and find the things that are wrong and do that in partnership. … (It is important) to have Aboriginal mental health workers to vouch for you, elders to hold your hand and lead you in. (P8)

However, this wasn't always easy, and one participant trained overseas admitted her vulnerability in not knowing about Aboriginal culture. Having never met Aboriginal Australians outside the workplace she was ‘fearful of doing or saying the wrong thing when working with (them)’ (P2). She also noticed how ‘white’ the service was, with no one from ‘non-white’ cultures in senior positions. She wanted to relate better to Aboriginal patients, and supported a more strategic, sustainable approach where cultural education and training were embedded in professional development. Another participant thought that ongoing cultural education should be mandatory, particularly when considering mental health assessment, diagnosis, and treatment:

If you are not trained, you might misinterpret what (an Aboriginal patient) has said or just because they have long silences or don't look at you. … So having various hypotheses related to Aboriginal issues is important. Is it delusional based, psychotic based, culturally based, or is there another reason? (P7)

Discussion and Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Survey Findings
  6. Interview Findings
  7. Discussion and Conclusion
  8. Acknowledgements
  9. References

The survey and interview findings suggest that non-Aboriginal health professionals want to improve care to Aboriginal patients, but are often constrained by both the forensic setting and policies and practices at the organizational or service level. While the findings of this current study support other evidence that structural or service issues constrained the implementation of culturally-safe care (Ziersch et al. 2011), they also revealed that the participants wanted to deliver high-quality care, but were unsure how best to do this in the therapeutic encounter, and wanted more education and training. The participants withstood frustrations and tensions inherent in their role, sometimes experiencing uncertainty, ambivalence, and ambiguity in interactions, but nonetheless persisted in seeking authentic points of connection with Aboriginal patients. They reflected on the quality of care they offered, and some were aware of the social, political, historical, and cultural contexts informing how their own position intersected with that of the Aboriginal patient. Many revealed an understanding of the interplay of power relations and were mindful of the need to respect cultural differences. Rather than expecting Aboriginal patients to conform to the dominant model of care, many participants were flexible so the space they created when caring for Aboriginal patients was inclusive, expansive, and held the potential for engagement and relationship building.

The need for ongoing and embedded education and training in delivering culturally-safe care to Aboriginal patients was identified as a key priority in research findings, with at least 37% of health professionals trained outside Australia with limited knowledge of Australian Aboriginal culture and social history. A lack of effective education and training in this area can lead to health-care practices that compromise the health of Aboriginal people (Boffa 2008; Yeates et al. 2009). Research in other areas of health care has shown that health services, however unwittingly, are often ‘colour blind’, and Aboriginal knowledge, beliefs, and values are subjugated to a dominant Western biomedical model of care (Durey & Thompson 2012; Kowal 2008). To become a ‘culturally-safe’ practitioner, cultural education programmes must promote critical self-reflection. In Australia, ‘whiteness’ or Anglo-Australian cultural dominance is the norm that shapes the lives of the privileged and the marginalized; the standard against which differences from the norm are measured, judged, and often ignored (Moreton Robinson 2009). However, such privilege is often invisible to those who are white, so education and training that critically reflect on the ‘invisibility’ and/or normalization of mainstream beliefs and practices are necessary to address inequitable power relations (Pease 2010) that, if left unacknowledged, can perpetuate discrimination and undermine the health of Aboriginal people (Larson et al. 2007; Pease 2010; Sakamoto 2007).

One of the challenges implementing education programmes to increase knowledge and understanding of Aboriginal Australian knowledge, beliefs, and values is avoiding tokenism, where health providers ‘tick a box’ for attending a workshop or seminar on ‘cultural education’ that meets institutional requirements for professional development, but might not translate to better practice (Durey 2010). Courageous conversations are needed on the intersection between race and inequity (Singleton & Linton 2006), where ‘self-reflexive grappling with racism and colonialism’ (Pon 2009, p. 60) can help identify factors influencing health professionals' care of Aboriginal patients. Education and training that theorizes notions of power in colonized countries, uses racialized language, and examines the role of ‘whiteness’ and privilege at interpersonal and systemic levels (Pon 2009; Sakamoto 2007) is seeking to avoid tokenism and deepen understanding of what constitutes ‘cultural safety’ for Aboriginal Australians and how it applies to practice.

Another key finding was embedding Aboriginal health providers in the service, and the need for them to be valued and supported members of the health team. Evidence suggests that culturally-safe care involves recruiting more Aboriginal health providers, as few are employed in mainstream health services proportionate to need (Felton-Busch et al. 2009). Strong evidence links Aboriginal health workers to good health outcomes for Aboriginal patients (Taylor et al. 2009) and better communication in health settings (Nagel & Thompson 2006). The Healthy Future for Western Australians (2004) report advocated recruiting Aboriginal employees and providing a supportive environment in which to work. Such environments could also reflect Aboriginal culture through signage, paintings, and language to help Aboriginal patients and staff feel included and welcomed (Thompson et al. 2011).

Developing therapeutic relationships in a forensic mental health setting that are respectful of cultural differences is key to building patients' self-esteem and fostering improved health outcomes (see O'Connor et al. 2010). Building strong partnerships between non-Aboriginal health professionals and Aboriginal health providers is also important to deliver culturally-safe mental health care (Sheldon 2010). This approach helps non-Aboriginal health professionals better appreciate and understand patients' social, cultural, historical, and economic contexts and the communities in which they live, all of which inform their life circumstances (Drew et al. 2010).

Our findings highlight the opportunity for organizational commitment to build on positive associations established in the therapeutic encounter by offering ongoing education, training, and support to develop and strengthen relationships between health professionals, Aboriginal health providers, and Aboriginal patients and their families. Such support to deliver high-quality care to Aboriginal patients is integral to the forensic mental health professional becoming a ‘thinking, culturally-safe practitioner’ as a ‘prerequisite for emerging as a clinically-safe one’ (McDermott 2012; 15).

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Survey Findings
  6. Interview Findings
  7. Discussion and Conclusion
  8. Acknowledgements
  9. References

Thanks to the Western Australian Nurses Memorial Trust Fund for supporting this research.

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  2. Abstract
  3. Introduction
  4. Methods
  5. Survey Findings
  6. Interview Findings
  7. Discussion and Conclusion
  8. Acknowledgements
  9. References
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