Time to bring down the twin towers in poor Aboriginal hospital care: addressing institutional racism and misunderstandings in communication
Angela Durey, Curtin Health Innovation and Research Institute, Curtin University, GPO Box U1987, Perth, WA 6845, Australia. Email: email@example.com
Improvements in Aboriginal health have been slow. Research demonstrates ongoing discrimination towards Aboriginal Australians based on race, including in health services, leads to poor health outcomes. Using an eclectic methodology based on observations and discussions with health practitioners experienced in working with Aboriginal patients, this paper identifies how cross-cultural misunderstandings undermine the quality of care to Aboriginal patients in hospital and offers suggestions for improving practice. It also explores the concept of institutional racism and challenges doctors to reflect on their role in perpetuating power imbalances. We argue that physicians and healthcare providers need to do more than just deliver evidence-based interventions, by critically reflecting on their own attitudes to and practices with Aboriginal Australians and work collectively to effect systemic change which creates a more inclusive and safe environment for all people accessing healthcare.
Breen and Goldberg recently documented not only the role of the physician in difficult encounters with patients but also the limited guidance available to recognise and improve communication.1 Their paper resonated with us given our many conversations with non-Aboriginal medical practitioners and other healthcare providers about dealing with the Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal) patients and their families. Why might interactions while treating Aboriginal patients be considered as difficult encounters? And why has the health of Aboriginal Australians been slow to improve despite increased dedicated funding? Many different responses are possible to these questions. Doctors are often participants in conversations about Aboriginal patients that include comments like ‘We don't understand why they don't . . . [come, present earlier, attend, look after themself, etc.]’?
In this paper, we highlight literature which describes the concept of cultural safety and draw upon research elucidating, at least in part, answers to the above questions. We argue that doctors, as leaders in the community and the health system, have outstanding potential to improve poor Aboriginal health outcomes, and we focus particularly on physicians for their involvement in the hospital-based management of chronic disease, which requires understanding how to facilitate long-term participation and adherence to treatment. To fulfil this potential, physicians need to ask themselves whether they are doing all they can as citizens and as doctors to improve the health of the most marginalised group of Australians since white ‘settlement’ who have the worst health status of any identifiable group. To do this requires doctors to reflect critically on their own privileged position in Australian society and the health system, their beliefs about Aboriginal Australians, their practices when interacting and treating them and their power to effect change in their own practice and the systems in which they work.
Health providers compromise good health outcomes by discriminating against patients and their families, however inadvertently, based on race or culture.2 The word which describes this, although it will not sit well with many, is racism, a concept described later in this paper. Being an Aboriginal Australian too often predicts poor socioeconomic status and life opportunities, both major determinants of poor outcomes in health, education, housing and justice.3,4 Given the history of discrimination since colonisation, it is unsurprising Aboriginal Australians have collective experiences and memory of abuse, discrimination and insensitivity including in accessing healthcare. Three out of four experience race-based discrimination5 and a central issue facing Aboriginal Australians is being treated respectfully so they feel safe in a mainstream health service environment.6 If they are treated disrespectfully or with indifference in hospitals, why should they accept and trust medical advice?
Our methodology is best described as eclectic. The authors have worked for many years in a variety of health settings including education, research and have experience in domains such as medicine, public health, policy and anthropology. We have drawn upon literature including peer-reviewed publications and government reports, formal qualitative research with Aboriginal people which explored their views and experiences;6–8 informal conversations with Aboriginal and non-Aboriginal friends and colleagues and observations made while working professionally in policy, practice and community settings. This approach was approved by the Western Australian Aboriginal Health Information and Ethics Committee. We are aware of the frustration many committed practitioners feel in their efforts to work in Aboriginal health, often defeated by a system that seems blind and indifferent to the needs of Aboriginal patients given their social and cultural circumstances.
Findings and discussion
Highly experienced practitioners working in Aboriginal primary healthcare over many years are frequently frustrated with a health system and care providers that do not recognise how cross-cultural misunderstandings undermine the quality of care to Aboriginal patients, particularly those admitted to hospital. Their insights are useful to encourage critical reflection on doctor–Aboriginal patient encounters and provide insights and lessons for practice.
A general practitioner (GP) working in an Aboriginal health service explained her difficulties with the system and its care for Aboriginal people.
An Aboriginal man, Mr K, was from the desert and he was wheeled in a wheelchair [to the Aboriginal health service]. I knew him well. He was a proud independent man and for him to agree to get into a wheelchair meant that the pain must have been excruciating. But he played it down, hardly complained because he was stoic, a tough old guy from the bush. So, even if he was asked to rate his level of pain, he wouldn't admit it was high. I wrote a detailed letter to accompany him but the health care professionals [in ED] did their own assessment based on his response. They didn't match his expression of symptoms with culturally appropriate care.
[GP working in an Aboriginal Community Controlled Health Service]
It is not surprising to any doctor that medical practitioners working in an Emergency Department (ED) make their own assessment of a patient referred by a local GP. What is notable about this account is that the ED assessment team did not include an Aboriginal health professional; did not know the patient, may never have sought or been offered training in culturally safe care of Aboriginal patients; did not involve a family member to assist in providing the history and ignored the detailed letter from an experienced GP who had worked for several years in the local Aboriginal health service and who knew the patient and about rural Aboriginal men's enculturation against expressing pain. Moreover, despite the effort made by the patient's GP in assessing and documenting the man's conditions, he spent 24 h in the ED, before finally being admitted to the intensive care unit. This either indicates the seriousness of his condition at the time of admission or reflects his deterioration during the delays within the ED.
The vignette illustrates the failure of good medical management by the system's inadequacy in responding effectively to this client's request for assistance with intolerable pain. A Western medical model of practice delivered to Aboriginal patients, particularly from remote areas where English is not their first language, can lead to cross-cultural misunderstandings of treatment that compromise health. The 2004–2005 National Aboriginal and Torres Strait Islander Health Survey found that, despite poorer health, many Aboriginal Australians do not seek healthcare because of access difficulties including cost, transport/distance, lack of available services and cultural barriers.9 There is a plethora of reports that support and explain this finding.10,11
Medical practitioners have an obligation to stay up to date, yet it may be unimaginable for them to understand the experience of people with relatively little health contact or enculturation to Western ways of thinking. How many would understand the following story told later by the patient about his anxiety in the hospital?
[When] they put an oxygen mask on Mr K, he thought they were trying to kill him. He said to himself ‘I decided to stay calm’ and would ‘give payback’ when he left. . . .
When he went to theatre he was frightened they were going to kill him. There was one Indian nurse with him and he decided to convince himself that she was Aboriginal and then he could cope.
We need Aboriginal Health Workers – and if we can't get them, who is next best?
[GP working in an Aboriginal Community Controlled Health Service]
Yet it is surprising how rarely medical specialists with a sizeable Aboriginal caseload in tertiary settings have demanded having Aboriginal health workers as part of their team when assessing and managing Aboriginal patients. Another example of cross-cultural misunderstanding is provided by a different healthcare provider.
I think on the whole white people misread Aboriginals in terms of how they respond, and I'll give you an example. The medical team on the ward will do a ward round and the Aboriginal patient is probably a little bit shy, a bit overwhelmed, spends a lot of time looking at the floor and looking away, not making eye contact, and the staff take that the wrong way . . . either [that] they don't understand or they don't care or they're not interested. They don't appreciate that there is a cultural aspect to that as well. So, then they're probably a bit dismissive of that patient and perhaps don't explain things as well to that patient as perhaps they might to someone else who they felt was engaging . . .
[Physiotherapist working in a tertiary hospital]
The lack of cultural sensitivity is also reflected institutionally.
Institutional racism refers to societal systems or patterns that have the net effect of imposing oppressive or otherwise negative conditions against identifiable groups based on race or ethnicity. Thus, hospital systems founded on a Western biomedical model of care and managed by mainly white middle class Australians living in the metropolitan area often fail to understand the language and realities of Aboriginal people living in remote areas. Consider the following scenario about patient admissions to a tertiary hospital in Perth where asking and recording Aboriginality and address falls to ED clerks on admission.
The clerks are sometimes nervous to ask about ethnicity. Theoretically they should ask everyone who comes through whether they are Aboriginal but that doesn't always happen. Addresses again. . . . potential for mistakes. For example the clerks sometimes ask ‘are you at the same address?’ and the patient will say ‘yes’ because there is no time frame given and they may have been at the same address for 3 months but they don't realise that the hospital record has a much older address. Also patients can be distracted or can't hear through the glass barrier or are just overwhelmed by all the questions so it is easier to say ‘yes’. What the clerks should say is ‘what is your current address?’
[Hospital-GP Liaison Officer]
The GP liaison officer describes how, at a fundamental level, the system fails Aboriginal people. Even if ED clerks ask where they are from, only one address can be recorded on the form. There is a field for ‘next of kin’, but, because of complex Aboriginal family structure, this may be insufficient and lead to the ‘next of kin’ being phoned but no one else, with the appropriate people never being contacted. This occurs despite Aboriginal clients and services asking that additional details are recorded. But since the IT system doesn't allow for that, inaccurate information is stored or ‘kept on a yellow sticky note on the clerk's desk which someone may or may not see’.
Similar problems occur when recording the patient's primary healthcare provider:
They will be asked who their GP is – and some people may not know what a GP is. Up north in the country they are not called GPs, they are called doctors, the clinic doctor or whatever. If the clerk deems they do not have a doctor, it is written down as ‘nil GP’ and there is no obligation to challenge that. If they are not sure they can write down ‘GP unknown’ and then they are under obligation to sort that out as a KPI. I think there is a tendency to put ‘nil’ as a default because it is less hassle.
[Hospital-GP Liaison Officer]
The doctor goes on to describe that over 20% of Aboriginal patients at this major tertiary hospital where 10% of the patients are Aboriginal have got ‘nil GP’. This compares to 6% for non-Aboriginal people. Yet the consequences of ‘nil GP’ are significant:
It means that the discharge letter is not sent anywhere. It should be printed out, photocopied and given to the patient but if the letter is not ready, the patient has gone before they have received it. They often turn up to me [in general practice] and I've not received a discharge letter, but the patient's got one in an envelope. It does work reasonably well. But you can imagine going up north – it could easily be lost along the way. Going through the file you see the letters ‘dear GP, acute on chronic renal impairment. Please check creatinine next week or hyper/hypo-tensive, please check potassium, on warfarin please check INR. Follow-up chest X-ray in 6 weeks’. And it just disappears into the nothingness. And as a GP you look for your follow-up instructions and to write in the GP file, what the patient has been admitted with, any update in medications, diagnosis and follow-up from that diagnosis. It is so important.
[Hospital-GP Liaison Officer]
Another key issue around quality of care in hospital is the failure to communicate effectively with primary care services. Emphasis has increasingly shifted to procedures to shorten hospitalisation that may impede opportunities for education and establishing links to primary care:
In the old days patients used to stay here about 6.7 days for an MI. Now it's 5.1. If you've got a small heart attack, 1.7 days. The significance of that is if you have a small heart attack, you have an emergency angioplasty. You're in the lab for three hours. You have a sheath for four hours. You're resting in bed for eight hours. You have a bit of a snooze. That's 24 hours gone. You have something to eat. You have a shower. That's another four hours . . . So . . . if patients are here 1.7 days, you need to start educating them from the time they get off the trolley (but) . . . Sometimes patients aren't interested either because they're tired, or in shock, or they've got family, or they've got visitors . . . Aboriginals tend to have a lot more family. Coronary care only lets you have two visitors at a time. So that means that if there are eight people out there, there's a constant turnover . . . The priority . . . is . . . to get people out. . . . you have reduced education time. . . . Also, if you're constantly turning over patients, it means you spend a lot of time admitting patients. So again, you don't have much time for education.
[Nurse working in Cardiology Ward]
Reflecting upon this, it is easy to see how Aboriginal people could be particularly disadvantaged, not because procedures aren't available and undertaken, but because the system operates against explaining and educating patients and their family about the significance of their heart attack and need for follow-up care. Hospitals may also fail to recognise the stress that primary care services are often under, particularly those with a high caseload of Aboriginal people.
Reflection and conclusions
Caring for Aboriginal patients requires communication skills that accommodate different styles of interaction and different understandings of and responses to illness.10,12 Cass and colleagues' seminal study showed that miscommunication between doctors and remote Aboriginal patients with renal disease was common and often went unrecognised, with a shared understanding of key concepts rarely achieved.13 Their analysis of miscommunication warrants careful consideration by all doctors, particularly ‘non-compliance’ in Aboriginal patients. Other studies reiterate the importance of history and language, building trust, giving adequate time to support effective communication in health encounters and the importance of Aboriginal staff as members of the healthcare team.6,14,15 And yet, healthcare providers may faithfully label and record a patient as ‘non-compliant’ and failing to attend for follow-up. It is reasonable to ask where the problem lies.
In the clinical encounter, recognising that a patient's world view on illness and care is ‘culturally shaped’ underpins effective care.16 Yet, how many physicians consider or address beliefs about disease attribution or spiritual aspects of care when dealing with Aboriginal patients? How many treat the whole patient as they hurry through rounds to make it to their rooms to see private patients? Change from ‘usual’ to ‘appropriate’ care requires that practitioners critically reflect on how their own beliefs and values about Aboriginal Australians impact on the quality of care. Such changes are important to reduce reluctance to seek medical care, discharges against medical advice, non-attendance at follow-up appointments and improve health outcomes.17
Good communication is integral to high quality care, and poses a significant challenge when English is not the patient's first language as extra attention is needed to build rapport and alleviate anxiety. For many Aboriginal patients, particularly those from the remote areas, a tertiary hospital is an alien and frightening environment: Mr K was no exception. In the scenario above, ‘culture blindness’, or ‘treating everyone the same’ was demonstrated when healthcare providers disregarded his social and cultural context, unaided by a system not requiring them to address these issues – no appropriate training in Aboriginal health, no Aboriginal worker on the team, no accountability in their (mis)management of the patient. Mainstream systems fail to accommodate the needs of Aboriginal (and other) clients, and tragically, many doctors and health providers have not been trained to think carefully of broader but important issues. Relevant questions for doctors who care for Aboriginal patients to consider are listed in Table 1.
Table 1. Questions for reflective practice to improve communication, avoid misunderstanding and the achieve culturally safe healthcare
|Have you attended training about local Aboriginal culture and belief systems? Do you check what training other staff in your team have attended?|
|Do you model cultural respect towards Aboriginal people and those of other cultures?|
|Does your organisation have a Reconciliation Action Plan? Do you know what is in it? How have you contributed to its development and implementation?|
|Do you see patients who are Aboriginal Australians?|
|What are the income, education and power differentials between you and an Aboriginal patient? How might this affect your interactions?|
|Do you have an Aboriginal person in your healthcare team? How well is your Aboriginal team member treated? Are they included in team meetings, and not exclusively expected to work with Aboriginal staff? What support mechanisms are in place to assist them in their work?|
|Is your hospital welcoming and safe to Aboriginal people who attend for care? Can they find their way around easily? Have you asked Aboriginal patients what they think?|
|How well do you engage the Aboriginal patient and their wider family in decision-making in relation to their care and subsequent management?|
|How do you talk with Aboriginal patients and family members? Do you know what community they are from? Are you sure they understand you and what you are saying? What are you doing to check that they do? How often have you used an Aboriginal interpreter to assist communication?|
|Do you treat the whole person or just the body part? Do you ask about the major concerns of your Aboriginal clients and their life circumstances as part of caring for them? What mechanisms for psychosocial support are in place for Aboriginal patients and their family members?|
|Do you ensure that when patients are discharged they will receive good follow up care – how? What healthcare resources are available in their home community?|
|After discharge, how do Aboriginal patients get home and how long does it take? What about their family members who supported them?|
|Does your system for communicating with primary care providers work for Aboriginal clients, not just those seeing urban GPs? How often do you ring the primary healthcare service to provide information and reinforce messages about the need for follow-up care of Aboriginal clients?|
|If the system is not working adequately for Aboriginal patients, are you constructively engaged in systems reform?|
|Are you part of the problem or part of the solution to poor Aboriginal health outcomes?|
Staff can inadvertently exacerbate the stress and pain of the patient. Showing respect includes knowing where Mr K lives, how many people live in his community, what language is spoken, Mr K's role in the community, how far to the nearest town, access and availability of transport and services and sensitive and culturally appropriate ways to alleviate anxiety. To ensure that relevant knowledge is accessed, such as where Mr K's wife is staying, whether they have been to the city before and whether they have family or support networks in the city, Aboriginal staff are a major resource who can assist understanding and improve health outcomes.6
Providing a culturally safe context to treat Aboriginal patients is important for good health outcomes.18 The evidence that discriminatory beliefs and practices based on race are bad for health and increase stress is unequivocal.2 Providers who reflect on their own beliefs and practices may find it confronting to realise they are part of the problem not the solution, because they deliver discriminatory rather than culturally safe practice.19,20 By identifying their own biases and assumptions practitioners are less likely to impose them on their patients.21 However, such understanding is only the first step and futile unless followed by improvements in attitudes and actions that effectively change otherwise predictable practices and outcomes.
Doctors are leaders in healthcare, yet making time for quality Aboriginal cultural orientation training to improve practice is often not their priority; in fact, they are the group least likely to attend. Rarely have doctors led the fight for more Aboriginal health professionals on their healthcare team, despite this being an effective way to learn more about Aboriginal health and culture.6 Doctors can improve their communication so their behaviours and practices promote the health of Aboriginal patients. Physicians' potential to act as powerful agents for systems change in hospitals can strengthen moves to increase Aboriginal patients' access, participation and adherence to evidence-based treatments. Cultural change is needed, and within the hospital, environment physicians have a pre-eminent leadership role to play to achieve this.
Possible ways forward
A key element to culturally safe care is encouraging committed physicians to engage with the Aboriginal community including patients, family members and Aboriginal health workers. They should actively support Aboriginal staff working in healthcare and could go even further by establishing contact with local Aboriginal elders, involving them in bringing together a reference group, discussing problems, planning effective outcomes and collaborating.22 Many systemic problems are reflected in interpersonal encounters and exacerbated by the throughput model of care with an expert dealing with a specific problem rather than considering the holistic, socio-cultural context in which the problem is embedded. Physicians are also well placed to identify and argue for changes to systemic problems in the delivery of healthcare, to be part of the solution and not conservative power brokers resisting change. Individuals can reflect on and change their own attitudes and practices, and lead system change for a more caring, responsive and inclusive health environment that focuses on healing rather than throughput.
Our sincere thanks to colleagues who contributed so generously to this paper.