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Southern Adelaide Local Health Network Patient Care Guideline Aboriginal and Torres Strait Islander

Acknowledgement The content of this booklet was adapted with permission from the original Patient Care Guideline that was researched and developed by the Aboriginal and Torres Strait Islander Cultural Capability Team and the State of Queensland Queensland Health The Artist Anna Pondi Title of the painting Don t feel like you re stuck in a web The Story The centre web is the circle of life the red and blue represents our veins the small circles are various cultures groups and families the foot prints are the steps we have to take throughout our lives with our spirits behind us the stars are germs and diseases and the handprints are of a baby People Sitting Emu Campsite Waterhole Animal Tracks Sandhill Bush Tucker Hunting Boomerang Rain Waterholes and Running Water Coolamon Honey Ants Boomerang Digging Sticks Spears Kangaroo Tracks Woman Man Woomera Shield Tracks Waterholes Meeting Place Person Goanna Disclaimer The information set out in this publication is current at the date of first publication and is intended for use as a guide of a general nature only and may or may not be relevant to particular patients or circumstances Nor is this publication exhaustive of the subject matter Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional and the premises from which the health professional operates While the text is directed to health professionals possessing appropriate qualifications and skills in ascertaining and discharging their professional including legal duties it is not to be regarded as clinical advice and in particular is no substitute for a full examination and consideration of medical history in reaching a diagnosis and treatment based on accepted clinical practices Accordingly The Southern Adelaide Local Health Network and its employees and agents shall have no liability including without limitation liability by reason of negligence to any users of the information contained in this publication for any loss or damage consequential or otherwise cost or expense incurred or arising by reason of any person using or relying on the information contained in this publication and whether caused by reason of any error negligent act omission or misrepresentation in the information This booklet was compiled by Bronwyn Pesudovs RN and Daphne Perry BN Grad Dip Cardiovascular Nursing Version 1 0 June 2016 as part of the LIGHTHOUSE PROJECT Phase II Email bronwyn pesudovs sa gov au or daphne perry sa gov au page 2

Contents Believe that you can make a difference 4 Aspects of Clinical Care 14 Purpose 5 Medical examinations 14 Factors influencing access to healthcare 6 Diagnosis and treatment 15 Cultural factors 6 Social and historical factors 6 Accessing services from remote locations 7 Providing culturally capable patient care 8 Culturally appropriate communication 9 Initial contact building rapport 9 Language 9 Doctor knows best view 9 Feeling shame feeling ashamed or embarrassed 10 Long gaps of silence 10 Lack of eye contact 11 Gathering information 11 Identification 11 Communication tips 11 The Hospital Experience 12 Environment 12 Traditional treatment 15 Decision making and informed consent 15 Consenting on behalf of children 15 Administration of medication 15 Pain Management 16 Patient discharge 16 Discharge against medical advice DAMA 16 End of life care 17 Communicating effectively quick tips 18 Overcoming barriers 18 Before talking with patients and their families 18 Talking with patients and their families 19 Other considerations 22 Terminology 24 Top Ten Tips 26 References and Links 28 Men s and Women s Business 12 Avoidance Relationships 12 Aboriginal Liaison Officers 12 Support person Escort 12 Visiting arrangements 13 We acknowledge that the land on which The Southern Adelaide Local Health Network SALHN conducts business are the traditional lands of the Kaurna People and that we respect their spiritual relationship with their country We also acknowledge the Kaurna People as the custodians of the Adelaide Region and that their cultural and heritage beliefs are still as important to the living Kaurna People today Please be aware that this Patient Care Guideline may contain photos of Aboriginal and or Torres Strait Islander people who may be deceased Aboriginal and Torres Strait Islander Patient Care Guideline page 3

Believe that you can make a difference We believe that Aboriginal Health is everyone s business Start with understanding that we all have a role to play in improving health outcomes for Aboriginal people Sharon Meagher Aboriginal Education Development Officer Centre for Education and Training Children Youth and Women s Health Service Women s and Children s Hospital Campus Karpa Ngarrattendi means to support to heal Aboriginal Health Liaison Officers play a major role in hospitals in many different areas such as supporting those Aboriginal patients and their families who use Flinders Medical Centre and the Noarlunga Hospital The Aboriginal Health Liaison Officers ensure that Aboriginal and Torres Strait Islander patients their escorts and family understand medical procedures and hospital routines They also liaise with health professionals to ensure all aspects of the patient s journey are considered in developing treatment plans Theresa Francis Regional Manager Aboriginal Health Services Southern Adelaide Local Health Network Noarlunga Clovelly Park Minunthi Tapa Inparrititya creating Pathways to meet one another and the Aboriginal Liaison Unit Karpa Ngarrattendi Flinders Medical Centre page 4

Purpose Healthcare is delivered in a demanding and complex health system where treatment of the patient s condition is the primary focus There are however some fundamental ways in which the health system can better meet the needs of Aboriginal and Torres Strait Islander people Taking a person centred approach i e looking at the whole person will not only ethically allow patients to be directly involved and empowered in their care but will take into account the patient s cultural and individual needs preferences beliefs values as well as their comfort and surroundings This approach will improve the patient s experience and health outcomes and benefit health services clinically and organisationally It is also aligned with the core principles of the Australian Safety and Quality Framework for Health Care and the Australian Charter of Healthcare Rights This guideline is designed as a quick reference tool to support healthcare staff in delivering safe clinically and culturally responsive inpatient care to Aboriginal and Torres Strait Islander patients The guideline provides general advice only and does not address the diverse cultural differences across Australia Background In comparison to non Indigenous people Aboriginal and Torres Strait Islander people experience far worse health for almost every major cause of mortality and morbidity continue to be hospitalised at much higher rates for most health conditions have poorer outcomes of care and have lower access to health interventions Access to healthcare continues to remain a significant problem for Aboriginal and Torres Strait Islander people Before even accessing the health system the health of many individuals and families is already compromised on a daily basis due to a number of structural and social factors living in regional and remote communities which are areas of socioeconomic disadvantage and where the greatest burden of disease exists due to a lack of access to preventative or illness management services From a service provision perspective the quality and level of healthcare can be influenced by performance gaps of the health system including access in addressing health needs cultural incompetence which research demonstrates is linked to risks and poor quality health outcomes communication barriers which research demonstrates may lead to adverse events and poor quality of care living in major cities urban communities in areas of great disadvantage low socioeconomic status and environmental and socio political factors a high prevalence of health risk factors Aboriginal and Torres Strait Islander Patient Care Guideline page 5

Factors influencing access to healthcare Cultural factors Health is traditionally a holistic concept for Aboriginal and Torres Strait Islander people It encompasses the physical social emotional spiritual and cultural wellbeing of the individual and the whole community This is a whole of life view and includes the concept of life death life Many Aboriginal and Torres Strait Islander people still retain this belief system however traditional cultures and beliefs have been challenged and influenced by many factors including Christianity since colonisation Aspects of Aboriginal and Torres Strait Islander cultures must be considered in the patient s clinical care to ensure their holistic health and individual needs so a one size fits all approach will not work Healthcare staff should also be aware that urban rural and remote Aboriginal and Torres Strait Islander communities will each have differing needs Differences also extend to certain cultural practices and beliefs between communities and language groups Kinship family obligations and responsibilities tend to be of greater importance than personal health needs Being part of a community for Aboriginal and Torres Strait Islander people brings responsibilities and obligations This includes obligations to attend funerals to participate in community meetings functions and various committees Individual family members and group members are expected to participate at various levels in order to ensure that family representation roles and responsibilities are met and carried out Each person is expected to fulfil his or her obligations These factors frequently contribute to patients discharging themselves against medical advice with obvious detrimental impact on their health The risk of self discharge may be reduced if elective procedures are planned around known cultural obligations Communication difficulties are known barriers to improving health outcomes for Aboriginal and Torres Strait Islander Peoples These difficulties include verbal and non verbal communication lowered health literacy and language and cultural differences The segregated practice of Men s and Women s Business is still a very real and fundamental part of cultural practice today page 6 The kinship system is a complex social organisation that determines how Aboriginal and Torres Strait Islander people relate to each other and their roles responsibilities and obligations to one another ceremonial business and the land The kinship system determines who marries who ceremonial relationships funeral roles and behaviour patterns with other kin Aspects of this system can vary between regions Central Land Council www ccl org au Social and historical factors To create a culturally safe environment health services need to give consideration to cultural and historical context For example many Aboriginal and Torres Strait Islander people relate sterile hospital environments to past mistreatment hence a level of mistrust is held towards health systems by some individuals and families today Hospitals may for some people symbolise a place for dying not healing Aboriginal and Torres Strait Islander families may experience the following fear and distrust of the mainstream health services and buildings which can be threatening and alienating perception of extreme imbalance of power due to history and disadvantage feelings of vulnerability isolation shame and disempowerment cultural misunderstanding stereotyping and disrespect inadequate time for effective healthcare financial burden accommodation and transport difficulties

It is important to remember that racism has strong historical links with health and for victims is aetiologically important in the causation of illness Racism is thought to impact adversely on health outcomes through pathways like chronic stress risky health related behaviours less use of preventative services and racialised patient health worker relationships Awofeso N 2011 Racism a major impendiment to optimal Indigenous health and health care in Australia Australian Indigenous health Bulletin 11 3 The social determinants of housing education employment access to justice and empowerment are directly linked to the disastrous health outcomes faced by Aboriginal and Torres Strait Islander people They are also directly linked to the ongoing effects of substance abuse family violence and child neglect and abuse The Central Australian Aboriginal Congress date unknown Aboriginal Health Social Determinants of Health http www caac org au aboriginal health social determinants of health Excerpt taken from Rebuilding family life in Alice Springs and Central Australia the social and community dimensions of change for our people Aboriginal and Torres Strait Islander Patient Care Guideline Accessing services from remote locations Many Aboriginal and Torres Strait Islander patients accessing or admitted to urban and metropolitan hospitals come from remote communities Patients often must travel long distances to unfamiliar areas where language and cultural differences will be likely barriers Concern or anxiety over family welfare community cultural obligations financial responsibilities or other personal issues can be overwhelming This emotional stress can be further heightened by other stressors including culture shock fear of being judged of the unknown of procedures and isolation and disconnection from family and social support networks page 7 Photo Jacqui Barker Arkaroo Rock Flinders Ranges

Providing culturally capable patient care In order to improve healthcare delivery and outcomes for patients from diverse cultures the healthcare system and its staff must be culturally capable Healthcare staff who work with the patient s belief system rather than against it or ignoring it will have greater success in providing culturally responsive care and improved outcomes This also involves staff being aware of their own cultural filters as we tend to interpret behaviours and decisions according to what makes sense in one s own culture Western culture takes a biomedical approach to healthcare However to Aboriginal and Torres Strait Islander people health means not just the physical wellbeing of an individual but it refers to the social emotional and cultural wellbeing of the whole community in which each individual is able to achieve their full potential as a human being thereby bringing about the total wellbeing of the community It is a whole of life view and includes the cyclic concept of life death life National Health Strategy Working Party 1989 page 8 Photo yaruman5 People Silhouette I think one of the greatest difficulties in hospital is that a patient can be so out of their own environment that they feel they have no autonomy no choice things are done not only for them things are done to them and they re a passive recipient of all this medical attention much of which they don t understand and much of which doesn t seem to have any particular immediate relevance to their needs Dr Justin Coleman Metro South Hospital and Health Service

Culturally appropriate communication Do not under estimate the power of conversation that occurs in Aboriginal and Torres Strait Islander communities Aboriginal and Torres Strait Islander people talk about their experiences to everyone If it is a positive experience this will benefit the reputation of the organisation as well as your own however a negative experience will reinforce barriers between the service and Aboriginal and Torres Strait Islander people Sad News Sorry Business Guidelines for caring for Aboriginal and Torres Strait Islander people through death and dying https www health qld gov au atsihealth documents sorry_business pdf Initial contact building rapport The first few minutes of your initial interaction with patients and their families is important Efforts to build the right rapport may help overcome individual barriers including any fears or perceptions patients escorts or their families may have Most of all it will help build trust and respect in you as healthcare staff and trust in the healthcare system To build rapport Greet people with warmth and friendliness Adopt non threatening body language and tone of voice Ask the person where they come from and if they or their family have been in hospital or visited the services before Identify a common view topic such as places you have visited any association with the Aboriginal and Torres Strait Islander community Tell the patient something about yourself Explain processes length of waiting times and provide general information housekeeping directions to cafeteria etc Show personal interest by asking how they feel Provide clarity or information if concerns are raised Language Many Aboriginal and Torres Strait Islander people do not speak standard Australian English as their first language but as a second or third language dialect When spoken English may differ in dialect and the meaning of words can vary with family and community influences Tonal differences colloquialisms and other elements may obscure meanings and in the process may prevent healthcare staff from recognising essential cues to respond appropriately Additionally although a patient and their support person may converse in English Aboriginal and Torres Strait Islander Patient Care Guideline it does not necessarily indicate the person comprehends the English language in its entirety If proficiency is low do not assume the patient is illiterate poorly educated or of low intelligence Aboriginal and Torres Strait Islander people tend to speak in narrative conversational styles using stories or by talking around the topic to illustrate a point Direct communication can be confronting for some people and may not encourage the patient to participate Aboriginal and Torres Strait Islander people are very astute with the use of non verbal communication and reading body language Be mindful of non verbal communication through hand signs facial expressions and body language Doctor knows best view The patient may be polite by smiling and nodding to show they are listening act as a good patient to show respect for the staff member s authority and position nod to agree or say yes for the purpose of wanting the consultation to be over or so that they are perceived as understanding what has been said be disinclined to openly disagree with staff in authority and to ask questions about side effects for example for fear of giving insult The doctors just need to maybe spend a little bit of time with the patient Find out about who they are who s their family maybe find out what country they come from Just have a little bit of a relationship with the patient on a personal level Form that connection first and then you ll get the trust from the patient Tanya Kitchener Indigenous Hospital Liaison Officer Metro South Hospital and Health Service page 9

Photo Sharon Wills Onkaparinga River Feeling shame feeling ashamed or embarrassed For Aboriginal and Torres Strait Islander communities the shame factor is not only connected with sensitivities and attitudes but cultural beliefs Patients may feel shame to share personal and private issues that they do not understand the medical matters being discussed and the shame may prevent them from communicating that they do not understand The issue of confidentiality is also linked with shame If a person believes there has been a breach it will be difficult for the patient to regain trust and continue using the service Shame refers to deep feelings of embarrassment being ridiculed losing face within a relationship disempowerment lack of control loss of dignity For Aboriginal and Torres Strait Islander people it goes far beyond mainstream understanding of shyness and embarrassment Aboriginal and Torres Strait Islander Cultural Practice Program Queensland Health page 10 Long gaps of silence Silence is used by Aboriginal and Torres Strait Islander people and is common in conversations Its meaning may vary amongst individuals communities and settings Some examples include being respectful contemplating what has been said and translating its meaning into the person s own language reflecting showing disagreement mistrust or discomfort in an unfamiliar environment The positive use of silence should not be interpreted as lack of understanding agreement or that concerns are not urgent In Western cultures gaps of silence must be immediately filled however when engaging with Aboriginal or Torres Strait Islander people be respectful of silence learn to relax observe the cues tune into speech patterns and local idioms and take your time before responding There are times when silence needs to be observed and taking your time before verbally responding is a mark of respect Aboriginal and Torres Strait Islander Cultural Practice Program Queensland Health

Lack of eye contact Communication tips In Western culture direct eye contact is perceived as a form of respect and trust However in Aboriginal and Torres Strait islander culture direct eye contact from others may be viewed as a sign of rudeness disrespect or even aggression Allow time to build a rapport For Aboriginal and Torres Strait Islander people avoidance of eye contact can also be associated with a number of factors including gender age shame mistrust being in a hospital environment and past negative experiences Healthcare staff should observe body language and level of eye contact being used by the patient Follow the lead of the patient and modify your level of eye contact accordingly Gathering information Patients may not be open to disclosing or sharing personal and private information unless a sense of trust has first been established Building rapport and trust will help to minimise misunderstandings and anxieties and optimise the accuracy of information Assistance may also be required in completing forms Listen and be patient allowing time for silence Adopt a non threatening body language and tone of voice Adopt a non judgemental attitude and approach Speak in plain English and take time to explain Avoid technical language abbreviations and medical jargon Use open ended probing non direct questions Use active listening skills Speak quietly if other people around Simplify forms and written information as much as possible Use visual aids to assist with explanations Always check to ensure that patients have understood what is being said Emphasise confidentiality but also be upfront about the limits of this confidentiality For additional information view Communicating effectively quick tips found on page 18 of this booklet When asked multiple questions Aboriginal and Torres Strait Islander people may not feel obligated to reply giving the impression the patient is uncooperative or unresponsive Explain first why the questions are being asked and ask each question one at a time Avoid asking compound questions e g How often do you visit your GP and what are the reasons that you don t If required engage the patient s support person or family member to help obtain information Identification Asking the question Are you of Aboriginal or Torres Strait Islander origin is a standard question that must be asked at admissions points Correct identification of Aboriginal and Torres Strait Islander people is critical to minimising risks providing relevant services such as the Aboriginal hospital liaison service and for monitoring quality safety and effectiveness Aboriginal and Torres Strait Islander Patient Care Guideline page 11

The Hospital Experience The patient and family s first perception of the health service will impact on their feelings of safety in accessing the service Services that are culturally respectful and safe are more likely to be accessed by Aboriginal and Torres Strait Islander people and contribute towards positive health outcome experiences Environment Tips to create a culturally safe environment include Promote Aboriginal and Torres Strait Islander cultures via artwork signage and erecting Aboriginal and Torres Strait Islander flags Promote and participate in events of cultural significance such as NAIDOC Week and the National Aboriginal and Torres Strait Islander Children s Day Use Aboriginal and Torres Strait Islander health resources such as brochures booklets and posters Seek advice from Aboriginal hospital liaison officers and or Aboriginal and Torres Strait Islander colleagues Explain the hospital system For example Visiting hours meal times places for family to wait and how they can access other services such as transport phones banks and food outlets Medicines and treatment times information about the doctor s and when they will visit Why medical and personal history is requested several times Men s and Women s Business Men s and Women s Business must be respected Female patients for example will be uncomfortable discussing sexual or reproductive health issues with male staff and vice versa for male patients and female staff Where same gender staff is not available explain this to the patient from the onset and ask the patient if they prefer their support person and or family member to be present page 12 Due to gender protocols it may also be inappropriate to place female patients in the same room as male patients If this is unavoidable explain the reason why the patient is being allocated a room with the opposite sex Ask the patient if there is anything that can be done to make them feel more comfortable for example keeping the curtain closed at all times Avoidance Relationships Be aware that Aboriginal and Torres Strait Islander kinship systems are complex and for some avoidance relationships may dictate that a sonin law cannot be in his mother in law s presence or a brother cannot use his sister s name You therefore may need to accommodate inpatients in separate rooms Avoidance practices refer to those relationships in traditional Aboriginal and Torres Strait Islander society where certain people are required to avoid others in their family or clan Avoidance relationships are a mark of respect Aboriginal Liaison Officers Aboriginal Liaison Officers ALOs play a pivotal role in providing support and assistance to patients their families and escorts including practical and emotional support advocacy referrals and assistance with discharge planning and transport From a cultural point of view they provide cultural safety and connection including externally with communities and can help patients understand information relating to their hospitalisation and treatment particularly if language is a barrier Support person Escort A carer family member or another member of the community will often travel with and accompany a patient for support It should not be assumed that the support person is next of kin or can legally sign informed consent The travel and hospital experience may also be stressful for the support person who may feel isolated and may have other responsibilities including caring for other family members Check if this person also requires support or assistance from the Aboriginal Health Liaison Unit

While the support person can assist with communication they should not be officially used as an interpreter It is strongly recommended that you engage an ALO to assist with translating medical terminology and general health and medical literacy Visiting arrangements Due to Aboriginal and Torres Strait Islander family kinship relationships and cultural beliefs a patient may be visited by large groups of immediate and extended family Engage ALO s where necessary when discussing with the patient their support person and or nominated spokesperson about The impact if any this may have on the patient s rest or care requirements or that of other patients in the ward The options available to the support person should they need to stay in hospital with the patient Where patients may be visited at the end stages of their life coordinate with the spokesperson of the family for the best way to accommodate all visitors for example limiting the number of family members at a time to see the patient Ensure visiting arrangements are also communicated to staff between shifts to minimise any confusion Who is the correct person to share information with and what information can be shared Negotiating options to accommodate the presence of visitors for example if the patient is in the ward you may want to consider a nearby lounge area as a waiting area or place to meet the patient Aboriginal and Torres Strait Islander Patient Care Guideline Selina Bell and Louise Brown May 2016 page 13

Aspects of Clinical Care I think it s really important for clinicians to realise that when a client or a patient comes to our services they come with their entire life Their relationships their immediate health issues their past issues their lives They re not just their illness and they re not just their condition or their reason for admission to hospital Jennifer Morton Nurse Educator Cunningham Centre Darling Downs Hospital and Health Service Medical examinations As previously discussed it is critical to build rapport prior to proceeding with medical examinations Culturally respectful communication is needed to accurately determine the patient s medical history and what the patient understands about their health condition Be mindful and respectful when asking patients what they believed caused their illness or injury as in Aboriginal and Torres Strait Island cultures ill health can be based on a belief that it was a natural physical cause or harm caused by spirits Please note that this is not necessarily a sign of mental illness but is a very real part of cultural and spiritual beliefs page 14 Photo Georgie Sharp Kick Those Heels Up Before proceeding to physical examination it is advised that you explain the need to touch the person why how and where Ensure that they are comfortable before commencing If appropriate ask the patient if they would like a support person present When undertaking the examination or any invasive procedure it is important to consider Men s and Women s Business as well as the shame confidentiality and privacy factors as previously discussed

Diagnosis and treatment Consenting on behalf of children Prior to discussing a diagnosis with a patient ask if they would like their support person to be present In Torres Strait Islander culture traditional adoption is still practiced This involves the biological parent s giving their child to another known person in the immediate or extended family to raise as their own When engaging with families about the matter of biological parents or legal guardians consenting on behalf of children ensure confidentiality and approach the issue with sensitivity and respect Engage with an ALO for guidance and for cultural protocols When explaining the diagnosis use jargon free language and provide further explanation of the potential cause of illness Visual aids such as diagrams models and film clips may be useful Seek assistance from the Aboriginal Liaison Office if required When discussing treatment be mindful of the patient s cultural or other beliefs Discuss options for treatment ask the patient about what type of treatment they believe they should receive what their main concerns and fears are and what may prevent them from completing the treatment Some patients will think of the impact on family extended family and community In these instances the patient s kinship relationships and community responsibilities and obligations may take precedence over their own health When available offer patients treatment options For example patients may prefer to take medication orally or by injection Traditional treatment Many Aboriginal and Torres Strait Islander people still use traditional medicine food and remedies and consult with traditional healers Making connection to country or traditional homelands and seas is also central to positive wellbeing and healing This may be one of the key reasons why patients may discharge against medical advice If traditional medicine food is used assess any adverse effects it may have with prescribed medication Seek advice from an Aboriginal Liaison Officer if the patient has indicated that he she would like to engage the services of a Traditional Healer Decision making and informed consent It is beyond the scope of this guideline to address all elements of decision making and consent For reasons relating to the patient s capacity communication abilities culture or other reasons they may wish to involve a third party in the decision making process This option allows the patient more time for consultation and to reflect and to seek additional support if required before coming to an informed decision Aboriginal and Torres Strait Islander Patient Care Guideline Administration of medication Many Aboriginal and Torres Strait Islander patients face a number of challenges managing or adhering to prescribed medication Factors include financial or access issues the way health staff interact with patients or the impact of other organisational aspects of patient care When consulting about medication Be aware from the onset if there will be any communication difficulties and take the appropriate measures such as engaging the ALO or an Interpreter service Ensure the support person and or family members are present with the patient Explain in plain English and clear details about why the medication has to be prescribed when and how to take it the duration how to deal with any side effects adverse reactions or associated risks e g sharing medication with others and storing it in a place that is not accessible to children Use visual aid methods where possible At the end of the consultation check that the patient support person and or family members understood all that was discussed Encourage the patient to talk to their local general practitioner pharmacist or health clinic about their medication and for any reassurance about safety and appropriateness Ensure medication information is provided in language that the patient can understand discussed with the patient s family and communicated to treating staff including those from primary healthcare services page 15

Pain Management When in pain Aboriginal and Torres Strait Islander people may be reserved and not likely to complain Keeping silent may be from fear of being separated from families being in an unfamiliar environment being chastised or fear of spiritual origins of pain These behaviours could easily be misinterpreted and the actual pain and its intensity and severity may be underestimated Signs that may indicate the patient is experiencing pain may include Minimal speaking Subtle body language Lying down on their side and avoiding eye contact Upon questioning turning their head away Hiding under their blanket When coping with pain some Aboriginal and Torres Strait Islander people may use centering a practice which can easily be interpreted as simulating sleep Centering is a process that involves withdrawing into one s self spiritually and psychologically to shut out the pain Support for families e g grief and loss support and financial support To minimise stress for the patient and their family communication between the hospital and community health staff and other support services must be effective Referrals by social work nursing and or the Aboriginal Liaison Office must also be communicated and recorded Discharge against medical advice DAMA Aboriginal and Torres Strait Islander patients discharge themselves from hospital without medical advice at much higher rates than other patients Underlying reasons may relate to what the person is experiencing This may include feeling that they are not being listened to and respected their fear of procedures sense of isolation or associating their experience with past traumatic experiences in institutions Other common reasons for DAMA are family and community obligations Healthcare staff should recognise these cultural differences of coping with pain and discuss pain management options in a respectful culturally sensitive way The patient should also be given information and support to understand and participate in their own pain management Unfortunately when people are discharged against medical advice in my experience you rarely see them again And that s an issue if the treatment was particularly important because often they won t interact with that service again Patient discharge Jennifer Morton Nurse Educator Cunningham Centre Darling Downs Hospital and Health Service Continuity of care may be a more significant challenge for Aboriginal and Torres Strait Islander patients When patients return to their communities provision of care may become the responsibility of Aboriginal and Torres Strait Islander primary healthcare services palliative care or other support services It is important that discharge planning includes strategies for Transfer of treatment information Discharge Summary Medication management Access to community services such as personal care support respite services Preventing the patient from discharging against medical advice requires an understanding of the patient s perception of their hospitalisation and treatment Building rapport communicating effectively forming a trusting relationship and making patients feel safe at the very beginning is important to this process To prevent patients from leaving Communicate clearly particularly about procedures and processes Gain an understanding of what the patient understands about their treatment Ask why the patient would like to leave Ask the patient for potential solutions page 16

Problem solve identified issues with assistance from the Aboriginal Liaison Office If a patient decides to leave Provide all relevant information Consider the patient s medical and non medical needs e g family social and economic needs Make appropriate referrals Follow up Reassure patients that they can return End of life care The content of this Patient Care Guideline is to provide general guidance only for carers of Aboriginal and Torres Strait Islander people who are faced with death Consult with an ALO to gain knowledge and understanding of cultural protocols before discussing any related matters with the patient and their support person and or family members Cultural practices relating to death and dying vary across all cultural groups Providing care in a culturally safe environment recognises the spiritual emotional and psychological importance and reality of where a patient may wish to be For many Aboriginal and Torres Strait Islander people it is important that they pass away close to their family and community and or on their traditional homeland For Aboriginal and Torres Strait Islander people certain cultural practices will need to be considered such as the role of the family and the community Briefly outlined below are some the guidelines as delineated in Sad News Sorry Business Guidelines for caring for Aboriginal and Torres Strait Islander people through death and dying https www health qld gov au atsihealth documents sorry_business pdf Support is essential for a person in the final stage of life However support may be difficult if the patient is not in their home town and away from family In such circumstances the involvement of an Aboriginal Liaison Officer ALO is beneficial Aboriginal and Torres Strait Islander Patient Care Guideline It is culturally inappropriate for a nonIndigenous health staff member to contact and inform the next of kin of a person s passing This breach of cultural protocol may cause significant distress for Aboriginal and Torres Strait Islander families connected to the person who has passed Seek cultural guidance from ALOs Early in the patients admission identify if the patient is Aboriginal and or Torres Strait Islander Then identify who would be the correct person to contact in the event of deterioration in health and death of the patient The patient and their family may be reluctant to acknowledge bad news In the lead up to the expected death of an Aboriginal and Torres Strait Islander person some Aboriginal and Torres Strait Islanders families may request a visit from a clergy or chaplain In Aboriginal culture it is taboo to mention or in some cases write the name of the deceased person Aboriginal people believe that if the deceased person s name is mentioned the spirit is called back to this world Some Aboriginal and Torres Strait Islander people maintain their cultural beliefs which is inclusive of spiritual beliefs about the causes of poor health These beliefs generally may conflict with western explanations and diagnosis of illness Understanding and demonstrating respect for the belief of the patient and family will assist with developing trust and rapport Customary practices following death differ between Aboriginal and Torres Strait Islander people For further guidelines go to the following link Sad News Sorry Business Guidelines for caring for Aboriginal and Torres Strait Islander people through death and dying https www health qld gov au atsihealth documents sorry_business pdf page 17

Communicating effectively quick tips Overcoming barriers Remember the past Remember that based on past experiences Aboriginal and Torres Strait Islander people may have distrust of all systems including the health system and staff and may feel fear or shame Environment Aboriginal and Torres Strait Islander flags artwork signage patient information and other visual cues communicate to Aboriginal and Torres Strait Islander people that the services are culturally safe and welcoming and a place that they can enter without discomfort Welcome Relationships first Tone of voice A smile and a nod are welcoming even without words Person before Business ask about family share information about you Speak in gentle tones High tones such as raising your voice may be perceived as patronising Do not speak too fast Slow down and be clear with your words Language Many Aboriginal and Torres Strait Islander people do not use standard Australian English as their first language In some cases it is their second third or fourth language Do not make assumptions about the level of English proficiency of a patient This includes level of literacy Making an assumption may offend patients and may result in broken trust and the patient may never return to receive care Be mindful and sensitive but not assuming that all patients have low levels of literacy Before talking with patients and their families Language Find out what language the patient best understands If English is limited arrange to have a suitable family member or interpreter an Aboriginal and Torres Strait Islander Hospital Liaison Officer or Health Worker may be able to assist Check that the interpreter or family member is familiar and confident with translating medical terminology Who Take the necessary steps to ensure that you will be speaking to the correct person This will depend on the information to be provided or sought Be aware of extended family and kinship structures particularly in relation to informed consent and who needs to be consulted regarding critical decisions to be made Men s and Women s Business It is important that staff working with Aboriginal and Torres Strait Islander people understand that segregated practice such as Men s and Women s Business is still very real and an integral part of cultural practice today Whilst it is not always practical ask a female patient if they would prefer to be treated by a female clinician If this is not possible ask the patient if they prefer for someone e g partner or relative to be present The same gender appropriateness applies for Men s Business continued page 18

Before talking with patients and their families Environment and confidentiality continued Ensure that you take the necessary steps wherever possible to avoid causing patients to feel shame Shame refers to deep feelings of embarrassment being ridiculed losing face within a relationship disempowerment lack of control or loss of dignity For Aboriginal and Torres Strait Islander people it goes far beyond mainstream understanding of shyness and embarrassment Discussing confidential matters in open public spaces should be avoided Be discrete specifically for issues such as sexual health Maintaining confidentiality is vital in building trust Time When providing services to Aboriginal and Torres Strait Islander people consider allocating extended consultation times or communicating with patients outside scheduled appointments Be aware that there are inappropriate times for communication such as during Sorry Business deaths and funerals and this takes precedence over individual health concerns Link to community Seek assistance from your local Aboriginal and Torres Strait Islander staff wherever possible to assist you with interpreting cultural assistance and if needed to link you with someone from the patient s community Talking with patients and their families Smile relax Introduction Rapport Listening Smile and relax to create a safe and approachable environment for the patient Introduce yourself warmly Take the time to build rapport and trust by asking where they are from e g who is their mob Ensure that you are actively listening Do not continually interrupt or speak over a patient If there is a silence watch for body language to gauge when it is appropriate to start speaking If the patient is looking around the room they may still be listening to you it may mean that they are avoiding eye contact Questioning Aboriginal and Torres Strait Islander people tend to prefer a less direct approach to communication therefore direct questioning is somewhat confronting and offensive The customary way of seeking information is to establish a two way exchange volunteering information of their own and hinting at what they would like to find out While direct questions are used in Aboriginal and Torres Strait Islander society to determine background information e g where a person is from detailed or personal information is sought through indirect questioning Do not ask the patient to continually repeat themselves Do not ask closed questions avoid yes no responses continued Aboriginal and Torres Strait Islander Patient Care Guideline page 19

Talking with patients and their families Eye Contact continued In western cultures if we fail to maintain appropriate eye contact we can be perceived as hiding something or that the person is not to be trusted However generally speaking use of indirect eye contact in Aboriginal culture implies respect Respect that some but not all Aboriginal and Torres Strait Islander people will therefore be uncomfortable with direct eye contact Direct eye contact with anyone other than one s most intimate peers or relations is seen as a sign of rudeness disrespect or even aggression and the appropriate strategy to convey polite respect is to avert or lower one s eyes in conversation In Torres Strait Islander culture eye contact with the same gender can be interpreted as displaying interest and providing honest information Across genders problems that may occur with eye contact include jealousy shame and disrespect Avoid cross gender eye contact unless the patient initiates and is comfortable in the clinical setting Respect Wait your turn to speak Do not mimic or attempt to speak a patient s language e g Aboriginal English or Torres Strait Islander Creole unless you are able to or permitted and advised to This will depend on the relationship and rapport established between yourself and the patient Personal space Be conscious about the distance to which you are standing near a person Standing too close to a person that you are unfamiliar with can make a person feel uncomfortable or threatened Silence In western cultures silence in the communication process is seen as a gap that must be immediately filled In Aboriginal and Torres Strait Islander societies lengthy periods of silence are the norm and are expected during conversation particularly during information sharing and information seeking Aboriginal and Torres Strait Islander people use silence to listen allow for consensus or to indicate non commitment The positive use of silence should never be interpreted as lack of understanding or agreement There are times when silence needs to be observed and taking your time before verbally responding is a mark of respect Touch Aboriginal and Torres Strait Islander people tend to be touchy with each other by nature However it is considered inappropriate and or offensive if you touch someone that you do not know well Touching very much depends on the context or environment as well as the existing relationship and rapport with the receiver Seek permission prior to touching especially if the person is unknown Once rapport is built touch may be comforting and respectful If you need to touch a patient for clinical reasons explain why it is being done continued page 20

Talking with patients and their families Titles continued The terms Auntie Uncle Brother or Sister should only be used once rapport is built and approval given Auntie and Uncle are terms of respect for someone older than you not necessarily an Elder or a relative Making decisions Ask them if they want the doctor to explain the information to someone else Kinship obligations and responsibilities may apply and therefore a decision requires further consultation with extended family members Always allow time for information to be understood It is considered more important to understand the information and make a decision that will be of benefit to the extended family regardless of the time taken to make that decision Be aware that there may be instances where non indigenous people could be asked to leave a meeting or room if Aboriginal and Torres Strait Islander people need to discuss cultural matters privately in order to make an informed decision Yes Aboriginal and Torres Strait Islander people have a tendency to agree with someone regardless of whether they actually agree with or understand what has been said to them It is customarily used to indicate a readiness for co operative interaction or resignation to the futility of the situation If you are unsure check their understanding by asking again If they appear agitated they may be saying yes to end the conversation because they want to leave This may be because they are uncomfortable or have other priorities If the patient repeatedly says yes immediately after a question ask them with respect what they understood from the last question If the patient is looking into their patient records while you are writing and talking and nodding their head it is likely to be a sign that they want to appear that they have understood although they probably have not Choices options Provide the patient with clear choices or alternative options for care For example some medications can be taken orally tablet or liquid or injected If the preferred options are available and patients are given a choice to have a level of ownership of medical management the likelihood of medical compliance is increased Avoid jargon Choose your words so that you avoid medical terminology or jargon Use plain English and or diagrams to clarify message and understanding Avoid confusion Be conscious that words mean different things to different people The same word could have a different meaning depending on the community that you visit To minimise the misunderstanding of words consult with Aboriginal and Torres Strait Islander work colleagues or local community members to build your knowledge of locally suitable and generally accepted words continued Aboriginal and Torres Strait Islander Patient Care Guideline page 21

Talking with patients and their families Clear instructions continued It is critical that the patient understands your instructions For example take until finished may be misunderstood as take until you feel better rather than take until all tablets are finished If the patient has a family escort with them explain so that they also understand the instructions Methods Use diagrams models film images and metaphors to explain instructions medical and surgical terms and procedures particularly with people for whom English is not their first language Other considerations Purpose Be very clear on your purpose and or motivation for engaging with Aboriginal and Torres Strait Islander people It is important to identify who you are and the reason you want to communicate Appropriate Introductions Ensure that you introduce yourself appropriately to Elders and community leaders spokespersons The same courtesy and manners you apply to dignitaries applies to Elders and Traditional Owners If you have not met the Elder do not assume it is okay to call them Auntie or Uncle if you do not have an existing relationship Seek guidance from the person introducing you to the Elder or ask the Elder what they prefer Time Western culture places a lot of emphasis on the concept of time especially in terms of meeting deadlines In Aboriginal and Torres Strait Islander culture the emphasis is on relationships This cultural difference directly influences planning decision making community patient engagement and communication For example government processes tend to focus on getting the job done following prescribed schedules supported by assertive and direct communication e g let s cut straight to the point Whereas Aboriginal and Torres Strait Islander people are less rigid when it comes to schedules Establishing and maintaining relationships are more important than time As mentioned previously the concept and use of time differs between Aboriginal and Torres Strait Islander culture and non indigenous culture Build in additional time wherever possible to ensure effective communication and understanding Promises Seek advice awareness Do not make promises that you cannot keep This leads to feelings of raised hope or a level of dependency If promises are not kept relationships and trust will be destroyed Always seek advice if you are unsure what to say or what to do Be prepared to admit mistakes or limited level of knowledge continued page 22

Other considerations continued Word of mouth Grapevine The quickest way to get information to Aboriginal and Torres Strait Islander people is word of mouth This is a well established informal networking system that has the power to influence trust rapport and respect to approved health practitioners and health services Vice versa it can be used to advise community members who not to trust in terms of their health Relationships contacts networks Be aware of community governance structures i e who to consult and who are the community representatives Be aware of significant national and local cultural events Respect Don t big note yourself This means acting like you know everything there is to know about a community or cultural business Regardless of how much experience you have to act in this way is disrespectful Aboriginal and Torres Strait Islander Patient Care Guideline page 23 Photo Georgie Sharp Billy

Terminology The purpose of these guidelines is to provide you with guidance on the appropriate terminology with respect to Aboriginal and Torres Strait Islander people and cultures You should be aware that terminology will vary between locations Aboriginal and Torres Strait Islander Peoples Aboriginal and Torres Strait Islander Peoples are Australia s original inhabitants The term Aboriginal is generally not inclusive of Torres Strait Islander people and conversely the term Torres Strait Islander is not inclusive of Aboriginal people when collectively referring to Australia s original inhabitants it is preferred that you use Aboriginal and Torres Strait Islander Peoples Indigenous As Indigenous is not specific some Aboriginal and Torres Strait Islander people feel the term diminishes their identity and therefore it should be avoided ATSI The abbreviation ATSI when used to describe people is offensive and should not be used in official documentation or in speaking Elder The traditional meaning of an Aboriginal and Torres Strait Islander Elder is someone who has gained recognition within their community as a custodian of knowledge and lore and who has permission to disclose cultural knowledge and beliefs Recognised Elders are highly respected people within Aboriginal and Torres Strait Islander communities Mob Mob is a term identifying a group of Aboriginal and Torres Strait Islander people associated with a particular place or country Mob is an important term for Aboriginal and Torres Strait Islander people as it is used to describe who they are and where they are from Mob is generally used between Aboriginal and Torres Strait Islander people Therefore it is not appropriate for non Aboriginal and Torres Strait Islander people to use this term unless it is known to be acceptable Traditional Owner Country Traditional Owner is an Aboriginal and Torres Strait Islander person or group of Aboriginal and Torres Strait Islander people directly descended from the original Aboriginal and Torres Strait Islander inhabitants of a culturally defined area of land or country and has cultural association with this country that derives from the traditions observances customs beliefs or history of the original Aboriginal and Torres Strait Islander inhabitants of this area Relationships to country are complex and interrelated The term country is often used by Aboriginal and Torres Strait Islander people to describe family origins and associations within particular parts of Australia Aboriginal and Torres Islander people have diverse relationships with connections to and understanding of the Australian environment Some of these relationships are based on traditional knowledge and practice that have been passed down from generation to generation while others have resulted from the various impacts of colonisation page 24

Sorry Business The period of mourning for deceased Aboriginal and Torres Strait Islander people is commonly known as Sorry Business In many Aboriginal communities there is a prohibition on naming someone who is deceased which may last for months or even years When this occurs a different name is used to refer to the person who has passed away Generally the face of the person who has died should not be shown without warning particularly to their own communities Community There are many different perspectives on what a community is In defining a particular community consideration should be given to stolen generations where a community may comprise of Aboriginal and Torres Strait Islander people from many areas of Australia whereas Traditional Owners of the Land are a particular group of people Aboriginal and Torres Strait Islander people may belong to more than one community including where they come from where their family is and what organisations they belong to However in Aboriginal and Torres Strait Islander cultures community is primarily about country extended family ties and shared experience It is however generally acceptable to use community to refer to Aboriginal and Torres Strait Islander people living in a particular geographical region Aboriginal and Torres Strait Islander Patient Care Guideline page 25 Photo Georgie Sharp Corporate Image

Top Ten Tips Caring for Aboriginal and Torres Strait Islander Peoples Utilise your Aboriginal liaison staff Aboriginal Health Liaison officers ensure Aboriginal and Torres Strait Islander patients and their families have access to mainstream health services They also assist with practical needs for patients and their escorts while they are in hospital Inform and involve Aboriginal Health Liaison officers from the moment a new patient arrives To build trust you need to make time Through a history of disadvantage isolation misunderstanding and disrespect your patient may have low levels of trust in the Health System To build trust and respect give your time listen and explain simply respect silence share a story or two and ensure comprehension to reduce the risk of your patient feeling ashamed or embarrassed Others are more important than self The Aboriginal and Torres Strait Islander Culture may put obligation and responsibility to family kinship and community before their own health Yes may not mean yes It is customary for Aboriginal and Torres Strait Islander Peoples to use Yes to indicate a readiness for co operative interaction or resignation to the futility of a situation as well as to agree Check their understanding by asking again and take time to ensure they understand listen to learn and book an interpreter if in need Show compassion and patience Eye contact Respect that some but not all Aboriginal and Torres Strait Islander people may be uncomfortable with direct eye contact Indirect eye contact in Aboriginal culture implies respect Respect they may not be looking directly but still listening page 26

Silence is golden Silence is commonly used by Aboriginal and Torres Strait Islander people in conversations It may be used to show respect for contemplation translation to own language showing disagreement mistrust or discomfort in an unfamiliar environment Respect the silence learn to relax use observation for cues and take your time responding Men s Business Women s Business Segregated practices such as Men s and Women s Business can be a very real and integral part of cultural practice for your patient Be considerate of same gender appropriateness and try to wherever possible match health worker gender to the gender of the patient Consent It can be customary for others from family or community to make the decision of consent or future healthcare for your patient Before informed consent can be taken know who is needed to be present or available to provide consent for your patient Take your time check their understanding and use Interpreters if unsure Doctor knows best The patient may feel he has to agree to show respect or want the consultation to be over or to be perceived as understanding to avoid embarrassment or shame Your patient may be disinclined to openly disagree or ask questions for fear of giving insult A little more time and a show of understanding may be enough to create trust and rapport creating an opportunity for the patient to be more open Discharge but where On discharge review where your patient is going to call home as not all remote health clinics are the same Services vary and some have no staff for weeks at a time The clinic may consist of a bed chair and health worker or be a large complex with a full team of medical staff Aboriginal and Torres Strait Islander Patient Care Guideline page 27

References and Links Aboriginal and Torres Strait Islander Cultural capability Queensland Health https www health qld gov au atsihealth cultural_ capability asp Awofeso N 2011 Racism a major impediment to optimal Indigenous health and health care in Australia Australian Indigenous Health Bulletin 11 3 www healthinfonet ecu edu au key resources bibliography lid 21292 Australian Indigenous HealthinfoNet 2105 Summary of Australian Indigenous health 2014 http www healthinfonet ecu edu au health facts summary Communicating Effectively with Aboriginal and Torres Strait Islander people Aboriginal and Torres Strait Islander Cultural Practice Program Queensland Health https www health qld gov au deadly_ears docs hp res comeffect pdf Guidelines for Aboriginal and Torres Strait Islander Terminology Queensland Health 2011 https www health qld gov au atsihealth documents terminology pdf Sad News Sorry News Guidelines for caring for Aboriginal and Torres Strait Islander people through death and dying https www health qld gov au atsihealth documents sorry_business pdf The Central Land Council Kinship and Skin names www clc org au The Central Australian Aboriginal Congress date unknown Aboriginal Health The Social Determinants of Health http www caac org au aboriginal health socialdeterminants of health Jacqui Barker Photographer Arkaroo Rock Flinders Ranges Page 7 http www jacquibarkerphotography com yaruman5 Photographer 2006 People Silhouette S30241 Page 8 https creativecommons org licenses by ncnd 2 0 Sharon Wills Photographer 2014 Onkaparinga River Page 10 https www flickr com photos sharonwills 17519585968 in album 72157652156244485 Morgan K Lawrence M date unknown Communication with Aboriginal Patients Photo Selina and Louise Brown FMC 2016 Page 13 Osborne K Baum F Brown L 2013 What works A review of actions addressing the social and economic determinants of Indigenous health Issues paper No 7 Produced for the Closing the Gap Clearinghouse Canberra Australian Institute of Health and Welfare Melbourne Australian Institute of Family Studies Georgie Sharp Photographer 2011 Kick Those Heels Up Flikr Page 14 www healthinfonet ecu edu au key resources bibliography lid 26675 Purdie N Dudgeon P Walker R 2010 Working Together Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice Australian Government Department of Health and Aging p181 185 http www healthinfonet ecu edu au keyresources promotion resources lid 17709 https www flickr com people georgiesharp https creativecommons org licenses by sa 2 0 Georgie Sharp Photographer 2006 Billy Page 23 https www flickr com photos georgiesharp 201584354 in album 201381 https creativecommons org licenses by nc 2 0 Georgie Sharp Photographer 2007 Corporate Image Andamooka Page 25 https www flickr com photos georgiesharp 1229635102 in album 201381 https creativecommons org licenses by nc 2 0 This booklet was compiled by Daphne Perry Bronwyn Pesudovs and the Lighthouse Team as part of the LIGHTHOUSE PROJECT Phase II Flinders Medical Centre SALHN Photo From Left Theresa Francis Jayme Bennetts Bronwyn Pesudovs Sabine Drilling and Daphne Perry page 28

Notes Aboriginal and Torres Strait Islander Patient Care Guideline page 29

Notes page 30

For more information Karpa Ngarrattendi Aboriginal Hospital Liaison Unit Level 2 Flinders Medical Centre Flinders Drive Bedford Park SA 5042 Hours Monday to Friday 9am to 5pm Telephone 08 8204 6359 Fax 08 8204 5486 This document has been reviewed and endorsed by consumers in February 2016 www ausgoal gov au creative commons Department for Health and Ageing Government of South Australia All rights reserved Version 1 0 dated 16 October 2015 Printed June 2016