Encounters with difference: Mental health nurses and Indigenous Australian users of mental health services

This article presents findings from the multi‐sited ethnography of mental health nursing practice as it relates to the care of Indigenous users of public mental health services in Australia. It provides an analysis of mental health nurses beliefs and ideas about Aboriginal and Torres Strait Islander people encountered over the course of this research. The Indigenous service user was positioned as Other to the non‐Indigenous mental health nurse, and to non‐Indigenous service users. Cultural difference and the legacy of colonization, including its impact on the health of Aboriginal and Torres Strait Islander peoples, contributed to these beliefs of alterity. Despite emphasizing the differences with Aboriginal and Torres Strait Islander people in mental health services, nurses did not clearly relate this to Indigenous ways of understanding ill health. While cultural differences were recognized, what they meant for the nurses or their nursing practice was interpreted in different ways. In these circumstances, approaches towards care for Aboriginal and Torres Strait Islander people varied between nurses.     

Creating walking tracks to success: A narrative analysis of Australian Aboriginal and Torres Strait Islander nursing students’ stories of success

Australian Aboriginal and Torres Strait Islander people have higher rates of morbidity and mortality than other Australians. One proposed strategy to improve this situation is to increase the participation of Aboriginal and Torres Strait Islander people, including Aboriginal and Torres Strait Islander nurses, in the health workforce. Although the numbers of Aboriginal and Torres Strait Islander students undertaking tertiary nursing courses have increased, completion rates have not kept pace. The study aimed to describe Aboriginal and Torres Strait Islander nursing students’ experiences of enablers for successful course completion and to develop a narrative of student experience. A qualitative study using a strengths-based approach with a narrative analysis of semi-structured interview data was conducted across four schools of Nursing in Queensland, Australia. Eight final-year Aboriginal and Torres Strait Islander nursing students volunteered to participate in the study. A collective story with the overarching plotline Creating walking tracks to success was developed. Six threads of experience emerged: Making a difference, Valuing Indigeneity, Healing strength of connections, Resisting racism, Embracing support, and persevering towards completion. Key success factors included resilient attributes, building supportive connections and having positive expectations of the future, along with sustained institutional support from Aboriginal and Torres Strait Islander nurse academics and clinicians. Development of tailored resilience-building training for Aboriginal and Torres Strait Islander nursing students and appointment of Aboriginal and Torres Strait Islander academics in Schools of Nursing that include such students may facilitate future successful completions in other programs.     

Mental Health Nursing Practice and Indigenous Australians: A Multi-Sited Ethnography

Criticism of public mental services provided to Indigenous Australians have persisted over the last two decades, despite several national reports and policies that have attempted to promote positive service change. Mental health nurses represent the largest professional group practising within these services. This paper reports on a multi-sited ethnography of mental health nursing practice as it relates to this group of mental health service users. It explores the beliefs and ideas that nurses identified about specialist mental health nursing practice and Indigenous Australians. The study found a disunited approach to practice during the fieldwork. Practice was expressed as a series of individual constructions built upon the nurses’ beliefs about Indigenous Australians and their experiences in practice with these peoples. The criticism of mental health services from Indigenous communities was understandable to the mental health nurses, but how they could address this through their individual practices was not always clear to them. The actions by public mental health services to improve cultural safety through generic training related to the broad area of Indigenous health and health service needs, does not appear to evolve into informed specialist mental health nursing practice for Indigenous Australian service users.     

An innovative nurse education program in the Torres Strait Islands

As the most numerous and geographically dispersed professional group, registered nurses in Australia work with Aboriginal and Torres Strait Islander health workers and other members of the multidisciplinary team in a variety of practice contexts to provide health care to Indigenous and non-Indigenous people. Despite the introduction of a variety of recruitment and proactive support strategies by employers, universities and State and Commonwealth governments, few Indigenous people in Australia enrol in, and graduate from, entry level higher education courses in the health professions. The reasons for this are complex and, as yet, not well understood or described; however, it is clear that the well-documented execrable health status of Indigenous Australians demands a response from universities, which are largely responsible for the education of health professionals. An innovative model of registered nurse education in the Torres Strait region of Australia is reported in this paper. A satellite campus established by James Cook University (JCU) on Thursday Island delivers the undergraduate nursing course by mixed mode, supplemented by specific strategies designed to improve Indigenous student recruitment and retention and thus increase the likelihood of graduation. The course and the strategies implemented are discussed in this paper.     

Review of Aboriginal and Torres Strait Islander content within a Bachelor of Nursing

BackgroundThere have been significant improvements in the past decade in the health of Aboriginal and Torres Strait Islander peoples however, the target to close the gap in life expectancy by 2031 is not on track to be met. The Aboriginal and Torres Strait Islander Health Curriculum Framework (The Framework) provides a guide for developing health professional’s cultural capabilities to enhance the service delivery to Aboriginal and Torres Strait Islander peoples (Australian Government, 2016).AimThe purpose of this study is to review Aboriginal and Torres Strait Islander content included in the Bachelor of Nursing Program at an Australian university, assessing alignment with The Framework.MethodsThis research utilises mixed methods to confirm the presence of Aboriginal and Torres Strait Islander curriculum in the Bachelor of Nursing program and to further explain these findings.FindingsThis study provides evidence that the Bachelor of Nursing program meets the Australian Nursing and Midwifery Council accreditation requirements, yet Aboriginal and Torres Strait Islander health content within the program is fragmented and inconsistent.DiscussionEnablers with the potential to align tertiary undergraduate Nursing programs with The Framework have been identified to facilitate embedding of appropriate content.ConclusionThe outcome of this study is a clear picture and the true nature of the content related to Aboriginal and Torres Strait Islander health within the Bachelor of Nursing curriculum and alignment with the expectations of The Framework, with a process that can be applied elsewhere.     

Owning solutions: a collaborative model to improve quality in hospital care for Aboriginal Australians

Well-documented health disparities between Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal) and non-Aboriginal Australians are underpinned by complex historical and social factors. The effects of colonisation including racism continue to impact negatively on Aboriginal health outcomes, despite being under-recognised and under-reported. Many Aboriginal people find hospitals unwelcoming and are reluctant to attend for diagnosis and treatment, particularly with few Aboriginal health professionals employed on these facilities. In this paper, scientific literature and reports on Aboriginal health-care, methodology and cross-cultural education are reviewed to inform a collaborative model of hospital-based organisational change. The paper proposes a collaborative model of care to improve health service delivery by building capacity in Aboriginal and non-Aboriginal personnel by recruiting more Aboriginal health professionals, increasing knowledge and skills to establish good relationships between non-Aboriginal care providers and Aboriginal patients and their families, delivering quality care that is respectful of culture and improving Aboriginal health outcomes. A key element of model design, implementation and evaluation is critical reflection on barriers and facilitators to providing respectful and culturally safe quality care at systemic, interpersonal and patient/family-centred levels. Nurses are central to addressing the current state of inequity and are pivotal change agents within the proposed model.     

Evolving beyond antiracism: Reflections on the experience of developing a cultural safety curriculum in a tertiary education setting

There is an inextricable link between cultural and clinical safety. In Australia high-profile Aboriginal deaths in custody, publicised institutional racism in health services and the international Black Lives Matter movement have cemented momentum to ensure culturally safe care. However, racism within health professionals and health professional students remains a barrier to increasing the number of Aboriginal and Torres Strait Islander Health professionals. The Australian Health Practitioner Regulation Agency's Aboriginal and Torres Strait Islander Health Strategy's objective to ‘eliminate racism from the health system’, and the recent adoption of the Aboriginal and Torres Strait Islander peoples led cultural safety definition, has instigated systems level reflections on decolonising practice. This article explores cultural safety as the conceptual antithesis to racism, examining its origins, and contemporary evolution led by Aboriginal and Torres Strait Islander peoples in Australia, including its development in curriculum innovation. The application of cultural safety is explored using in-depth reflection, and the crucial development of integrating critical consciousness theory, as a precursor to culturally safe practice, is discussed. Novel approaches to university curriculum development are needed to facilitate culturally safe and decolonised learning and working environments, including the key considerations of non-Indigenous allyship and collaborative curriculum innovations and initiatives.     

Evaluation of staff cultural awareness before and after attending cultural awareness training in an Australian emergency department

IntroductionCultural awareness of emergency department staff is important to ensure delivery of appropriate health care to people from all ethnic groups. Cultural awareness training has been found to increase knowledge about other cultures and is widely used as a means of educating staff, however, debate continues as to the effectiveness of these programs.AimTo determine if an accredited cultural awareness training program affected emergency department staff knowledge, familiarity, attitude of and perception towards Australian Aboriginal and Torres Strait Islander people.MethodOne group pre-test and post-test intervention study compared the cultural awareness of 44 emergency department staff towards Aboriginal and Torres Strait Islander people before and after training. The cultural awareness training was delivered in six hours over three sessions and was taught by an accredited cultural awareness trainer.ResultsThe cultural awareness training changed perception but did not affect attitude towards Aboriginal and Torres Strait Islander people in this group.ConclusionFuture strategies to improve staff cultural awareness need to be investigated, developed, implemented and evaluated.     

Hospital service use in the last year of life by Indigenous Australians who died of heart failure or cardiomyopathy: A linked data study

BackgroundAboriginal and Torres Strait Islander peoples experience disproportionate rates of heart failure. However, information regarding their use of hospital services in the last year of life is poorly delineated to inform culturally appropriate end-of-life health services.ObjectivesTo quantify hospital service use in the last year of life of Aboriginal and Torres Strait Islander peoples who died of heart failure or cardiomyopathy in Queensland, Australia.MethodsA subgroup analysis of a larger retrospective linkage study using administrative health data in Queensland, Australia. Individuals that identified as an Aboriginal and Torres Strait Islander person from their first hospital admission in the last year of life, who died of heart failure or cardiomyopathy from 2008 to 2018, were included.ResultsThere were 99 individuals, with emergency department presentation/s recorded for 85 individuals. Over 50% of individuals presenting to the Emergency Department were from regional areas (n = 43, 51%). The 99 individuals had a total of 472 hospital admissions, excluding same day admissions for haemodialysis, and 70% (n = 70) died in hospital. Most admissions were coded as acute care (n = 442, 94%), and fewer were coded as palliative care (n = 19, 4%). Median comorbidities or factors that led to hospital contact = 5 (interquartile range 3–9).ConclusionAcute care hospital admissions in the last year of life by this population are common for those who died of heart failure or cardiomyopathy. Multimorbidity is prevalent in the last year of life, underscoring the importance of primary health care, provided by nurses and Indigenous health workers.     

Therapeutic relationships,risk, and mental health practice

Despite significant changes to mental health services, nurses remain the professional group most likely to be in close contact with people who experience mental health problems. A core part of the contemporary identity of the mental health nurse is one who is able to provide acceptance and support for an individual's recovery through the therapeutic relationship. Yet there have always been some tensions with the mental health nursing role that can appear to challenge this relational focus. An increasing prominence of risk management in mental health care can position mental health nurses as responsible for enacting restrictions and has reignited interest in the role of mental health professionals in social control. This paper reports on one part of a multiple case study, which aimed to explore mental health professionals’ experiences of such tensions in the context of decision‐making. Interviews and observations were undertaken in acute ward and assertive outreach settings. Findings suggested that risk dominated decision‐making to such an extent it defined the way service users were understood and treated. A distant relationship between professionals and service users helped to create and maintain this situation. There needs to be a greater focus on service users’ subjective experiences in the decision‐making process to challenge the definition of people with mental health problems as risky.     

Use of emergency departments by Aboriginal and Torres Strait Islander people

Objective: To review published Australian literature about ED care of Aboriginal and Torres Strait Islander peoples. Method: Six databases were searched electronically for articles about ED use by Indigenous people in Australia. This strategy was complemented by manual searches of two websites, Emergency Medicine (1994–2004) and three bibliographies. Results: Aboriginal and Torres Strait Islander peoples attend EDs about twice as often as other Australians. The waiting times of Indigenous patients are similar to, or slightly shorter than, those of non‐Indigenous patients. However, more Indigenous than other patients choose to walk out before being seen, indicating possibly greater Indigenous dissatisfaction with ED care. Conclusions: Further conclusions of the present literature review were limited by contradictory results in the few studies of reasonable quality and by general concerns about data quality, especially the poor (but slowly improving) identification of Indigenous people in routine ED data sets. Closer collaboration between ED staff and Indigenous hospital liaison staff, combined with regular monitoring of routinely‐collected ED data, have the potential to improve Indigenous ED care and so contribute to improvements in Indigenous health.     

The Yapunyah project: embedding Aboriginal and Torres Strait Islander perspectives in the nursing curriculum

The Yapunyah Project is an initiative of the Faculty of Health at Queensland University of Technology. It was instigated to further improve the development of cultural competence in health graduates with respect to Aboriginal and Torres Strait Islander perspectives. The project was informed by the cultural competence in healthcare delivery models of Campinha-Bacote (1998a) and Cross, Bazron, Dennis and Isaacs (1989) and by the cultural safety reforms to nursing curricula in New Zealand. The Yapunyah Project involved extensive consultation and collaboration with Indigenous staff and health experts in the local Aboriginal and Torres Strait Islander community. A core curriculum, and associated graduate transcultural competencies, were informed by these discussions and earlier reforms in health curricula by the Committee of Deans of Australian Medical Schools and the Royal Australian College of General Practitioners. Although the overall project involved four separate schools within the faculty, this paper details the experience of embedding Indigenous perspectives within the undergraduate nursing curriculum. The experience has been a challenging and positive one, and the reforms have been supported by a sustainable framework. This paper outlines how one university faculty is endeavouring to educationally prepare nursing students to practice with evidence-based transcultural nursing knowledge based on culture care values, beliefs, and traditional lifeways of Indigenous people of Australia. As such, the project aims to contribute to the improvement and promotion of the health and well-being of Indigenous Australians in culturally and ethnohistorically meaningful ways.     

Tjirtamai--'to care for': a nursing education model designed to increase the number of Aboriginal nurses in a rural and remote Queensland community

In 2009, a nursing education model was locally designed and delivered to support the interest of a group of Aboriginal community members living in a rural and remote town in Queensland, specifically to prepare for entry into further nursing education. Named 'Tjirtamai' by the traditional owners of the area, the program was offered in recognition of the challenges faced by Aboriginal people when they enter nursing education courses and as a way to increase the local number of Aboriginal nurses. This program, while funded by the Government, had unprecedented support and involvement from both the local Aboriginal and wider community. The model offered multiple exit points, assistance with financial and other known challenges for Aboriginal and Torres Strait Islander students, and included contextualised literacy and numeracy. Of the 38 Aboriginal students who enrolled in the course, 26 students completed. Of those students, 18 have since enrolled in a bachelor degree in nursing while another 4 enrolled in a diploma of nursing. This paper provides an overview of the course and its outcomes.     

Equity in clinical practice requires organisational and system-level change – The role of nurse leaders

BackgroundIn the International Year of the Nurse and Midwife 2020, nurses in Australia and around the world are being encouraged to lend their voices to lead change. The COVID-19 global health crisis has highlighted the critical role of nurses in our community in ensuring that the challenges to our health care system are being met and overcome. It has also brought attention to existing health inequities in our community, in particular the poorer health of refugees, some culturally and linguistically diverse communities and Aboriginal and Torres Strait Islander peoples.AimTo call on nurses and nurse leaders to take greater action to improve health equity.MethodsThis paper presents a discussion with regard to the importance of equitable and safe clinical practice and the urgent need to address organisational and system-level barriers to the provision of equitable health care.FindingsClinicians’ abilities and capacities to provide equitable care is ultimately shaped by health care organisations and the broader historical, political, social and economic context of our community.DiscussionEquity should not only be reflected in clinical practice, but also in organisational policies and procedures, embedded in key performance indicators and supported by adequate funding and resources.ConclusionSystemic inadequacies are likely to be further amplified during times when the health system is under additional pressure. Nurses and nurse leaders should take this opportunity to reflect upon the integral role they play in addressing organisational and system-level change to ensure equity in health care delivery. We call on nurse leaders and the nursing profession to lead us all to a more equitable health care system and society.     

Too Busy to Talk: Examining Service User Involvement in Nursing Work

Traditional ideas of mental health nursing are challenged in contemporary healthcare settings by developments focussed on more partnership and collaboration with people using mental health services. Yet service users have reported limited involvement in planning their own care. The purpose of this research was to explore accounts from multiple perspectives about service user involvement in mental health nursing processes. Qualitative research interviews and focus groups with mental health nursing students (n?=?18), qualified nurses (n?=?17) and service users (n?=?13) were conducted, audio-recorded and transcribed verbatim. Participants’ transcribed talk was thematically analysed to examine understandings about service user involvement and mental health nursing. Nursing work was often described as task-focussed, with limited collaboration with service users in areas like care planning. Service user involvement was seldom mentioned by nurses themselves, indicating it did not form an important part of mental health nursing processes. Mental health nurses appear to be complicit in care processes that do not include involvement of service users and may discourage novice practitioners from attempts at engagement.     

Leadership enhancing culturally safe models of care in a Western Australian Aboriginal community context: A qualitative investigation

BackgroundModels of care for community health nursing need to address social determinants of health for families, requiring community health nurse leaders to encourage all nurses to facilitate culturally safe models of care, particularly for vulnerable and underserved populations. Many challenges impact on provision of support for a range of population groups, with increasing attention focusing on how community health nurses lead equitable health activities for Aboriginal Australian families.AimThe aims of this study were to investigate the suitability, feasibility and acceptability of parent support, informing a culturally safe model for a peer-led support program for Aboriginal families.MethodsParticipatory action research enabled Aboriginal peer support workers and parents, community agencies and a child health researcher to collaboratively review cultural safety, suitability, and progress of the program. Qualitative data were analysed through thematic analysis.FindingsThe Australian Health Practitioner Regulatory Agency's cultural safety framework guided four themes: Acknowledgement of colonisation, racism, and social determinants of health; recognition of influences of personal racism and power differentials; recognising importance of partnership approaches to care and collaboration with individuals and families to ensure appropriate and acceptable care; and promotion of safe working environments.DiscussionCommunity-based initiatives informed by Aboriginal perspectives are needed to support Aboriginal families. Participatory action research enables community health nurse leaders to engage with Aboriginal participants, facilitating co-design of culturally safe models of care.ConclusionReflections on culturally safe strategies enabled development of peer-led support for Aboriginal families, focusing on self-determination, empowerment, and equity. Acceptability of the strategies has contributed to an emerging culturally safe model of care. Indigenous Australian peoples are people who identify as Aboriginal or Torres Strait Islander. Respectfully, throughout this paper, they will be described as Aboriginal.     

ACEM adding its voice to the Voice hits the wrong note

ACEM has endorsed the proposal for an Aboriginal Voice to Parliament in Australia as a means of delivering its objectives to provide culturally safe care in EDs and to improve health outcomes for Aboriginal and Torres Strait Islander people. Unfortunately the Voice proposal has become a politically conentious issue. There is currently insufficient detail about how the Voice would operate and whether it will achieve the outcomes its proponents intend. This article argues that the claims in the ACEM statement are speculative rather than based on facts. In addition, by taking a position on this complex and controversial political matter ACEM is operating beyond its remit and risks distracting attention from its core mission.     

Measuring the evidence: Reviewing the literature of the measurement of therapeutic engagement in acute mental health inpatient wards

Quality nursing plays a central role in the delivery of contemporary health and social care, with a positive correlation being demonstrated between patient satisfaction and the quality of nursing care received. One way to ensure such quality is to develop metrics that measure the effectiveness of various aspects of care across a variety of settings. Effective mental health nursing is predicated on understanding the lived experiences of service users in order to provide sensitively‐attuned nursing care. To achieve this, mental health nurses need to establish the all‐important therapeutic relationship, showing compassion and creating a dialogue whereby service users feel comfortable to share their experiences that help contextualize their distress. Indeed, service users value positive attitudes, being listened to, and being able to trust those who provide care, while mental health nurses value their ability to relate through talking, listening, and expressing empathy. However, the literature suggests that within mental health practice, a disproportionate amount of time is taken up by other activities, with little time being spent listening and talking to service users. The present study discusses the evidence relating to the therapeutic relationship in acute mental health wards and explores why, after five decades, it is not recognized as a fundamental metric of mental health nursing.