IJERPH | Free Full-Text | Putting Indigenous Cultures and Indigenous Knowledges Front and Centre to Clinical Practice: Katherine Hospital Case Example
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2.3. What Katherine Hospital’s Management and Clinicians Did?
Katherine Hospital implemented a range of strategies to address the high rates of Aboriginal people taking their own leave, including providing additional support to junior clinicians [26].
Specifically, consideration was given to cultural factors, as was the case for a Jaowyn Elder who arrived with acute kidney failure. Without dialysis at a tertiary institution such as the Darwin Hospital, some 300 km away, she was unlikely to survive the weekend [26]. As a hospital clinician said, while:
“going to Darwin might save her life … Darwin hospital is too far from her Country and family”
The Jaowyn Elder’s spiritual connection to Country and family became paramount and limited any immediate transfer to a tertiary institution like the Darwin Hospital. However, the service system often does not understand the importance of an Aboriginal Elder’s connection to their Country and family. For Indigenous Australians, ‘Country’ is far more than a reference to land or a home; it is a unique connection to land, like a family bond. ‘Country’ has inherent associations with spirituality, tradition, and ownership as the foundation of social structures, systems, and cultural practices entwined with the land. This relationship is vital for identity, health, and wellbeing [33].
As one study participant said:
“it can be a real battle and a fight … just getting the system to understand the importance of being on Country, if you’re gonna pass away. The importance of being treated closer to home and all those sorts of things. How can we improve that for people? So, it basically means they have to leave Country and I guess the outcomes aren’t good because people quite often just stop halfway, they don’t want to be removed from Country, they don’t wanna not have their family around them. That whole patient journey is really critical because of the vast distance between regional centers and [tertiary] hospital”.
(P1, personal communication, June 2018)
While another non-Indigenous study participant expressed:
“I absolutely understand the connection to land, there is this deep, deep and ancient attachment to land. But how do I actually turn that into some words that are around, you know, what does this mean in a practical sense?”.
(P3, personal communication, June 2018)
A hospital clinician (on the radio program) went on to say:
“so, the doctors are about to negotiate with her … it will be complex and requiring great knowledge in understanding about her culture and wishes … We will have to have a conversation … and it be good to have that with all the family”
Who then added:
“so the ED staff will be in the process of getting the family in to have a family discussion … she needs a big boss doctor to have that conversation with her and her family, and the family will know who the boss doctors are … and they will expect to have the boss doctor to talk to them”.
Talking to family and not an individual, as expected in western non-Indigenous nuclear families, meant doctors acquired an understanding of the broader family structures and relationships in Aboriginal societies. Understanding the complexities and sensitivities of Aboriginal kinship relationships, particularly relational taboos, must be paramount. Neglecting such understanding compromises care [26]. As one study participant said:
“When you go to practice … you might not be aware [of] kinship relationships, of all these relationships … Some places these are very strong … brother sister … in some places you can’t … young men can’t talk to their sisters … so avoidance relationships … unless you understand that they’re operating … you’re going to end up doing something very silly”.
(P9, personal communication, August 2018)
Adding:
“if you don’t have any cultural background or an education in what sort of cultural imperatives might be … when you go to practice, those things will be a challenge because you might be aware of them necessarily, you might not be aware”
(P9, personal communication, August 2018)
who went on to say:
“[I] spent a lot of time where I went to work in the [de-identified] Country. I went and learned language so I could understand. I went and did some fairly, basic anthropology just so I could understand relationships, in the kinship system”
(P9, personal communication, August 2018)
Concluding that:
“if you understand that that’s how the community sees itself, then it becomes easier to develop policy around how you practice healthcare”
(P9, personal communication, August 2018)
Understanding cultural imperatives became apparent when treatment plans at Katherine Hospital began to integrate bush medicines and traditional healers into patient care. As a hospital clinician said:
“they want to put the bush medicine cream on them … I’m always happy for them to do whatever and sort of incorporate that in our treatment plan as well. So, this is what we’ll do with white man medicine, but we will also add … you know, we can do bush medicine as well for you if you bring it in”
Further adding:
“I think in the meantime, we try to be relatively respectful in terms of bush medicine and black magic and witch doctors and things, and encourage it if they’d like to have that as part of their treatment, then certainly facilitate it”
The term ‘black magic and witch doctors’ is used colloquially when describing the need for increased recognition and inclusion of diverse health beliefs and practices.
One study participant exclaimed:
“Mum uses something called [de-identified] … its properties are more sort of antiseptic, but you can also like drink it, and it will clear up any wounds really quickly, and if you’ve got a cough … a really, powerful bush medicine,… so how could we, … we should be tapping into that and actually, revitalizing that whole area of knowledge”.
(P11, personal communication, September 2019)
The incorporation of bush medicines as an integral part of an Aboriginal patient’s care and inclusion of such treatment into their management plan is an example of implementing or embedding the cultural beliefs, knowledges, and practices of Aboriginal people into clinical care.
Additionally, understanding that the dialects spoken by Aboriginal people require interpreter services to minimise communication barriers was also considered. As one hospital clinician expressed:
“English isn’t their first language. It may not even be their second or third either. If there’s any doubt, we get interpreters in, or even on the phone”.
A study participant reinforced:
“so, when trying to get someone to talk about their symptoms, unless they’re asking the right questions and drawing it out and the then patient needs someone who can interpret stuff a little bit and make them feel comfortable because a lot of people don’t want to talk about things … I think there’s too many opportunities for errors then. You need someone who can sort of do that sort of interpretation … cause language is still such a big barrier”
(P11, personal communication, September 2018)
Importantly, metaphors were often used as the dialect had no word(s) to explain certain conditions like cancer. In the radio program, one hospital clinician described a fungal infection, for example as:
“You know like mushrooms growing”.
Diabetes described as:
“sticky red blood that clogs up the pipes and causes blockage … how a medication will help pull the sugar out of the blood”.
Critically, Katherine Hospital management team and clinicians also understood that:
“the responsibility to understand Aboriginal culture and worldviews became the business of everyone and not simply left to Aboriginal staff such as the Aboriginal Hospital Liaison Officer”.
However, as stressed by a study participant:
“colonization has had an impact on culture and language too, across the nation… and, it’s so critically important for a lot of the policymakers and the influencers to gain that understanding as well”
(P15, personal communication, September 2018)
This may enable policymakers, service providers and clinicians to become effective allies and accomplices in enabling, embedding, and enacting Indigenous cultures into policies, programs, and services [5].
The positive outcomes in this Katherine Hospital case example would not have been possible without clinicians practising as effective allies and accomplices to Indigenous Australians and their families when presenting for treatment and care.
2.4. Allies and Accomplice’s Role—Supporting Integration of Indigenous People’s Culture into Clinical Practice and Services
Working as a genuine non-Indigenous ally or accomplice to Aboriginal people in healthcare requires a critically reflective, culturally sensitive, and focused approach. When non-Indigenous healthcare professionals gain experience and knowledge about working in a culturally safe and capable way that is free of racism, they begin to grasp what being a true accomplice or ally looks like in their everyday practice [34]
Allies promote Indigenous voices above their own and may call out blatant instances of racism; however, they can struggle to identify institutional and individual micro-aggressions that embed racism and disrespect into healthcare in Australia. Accomplices, however, are prepared to stand up alongside Indigenous colleagues and clients, knowing when and how to step back to enable their Indigenous colleagues’ authority and the right to decide and define what action is required. Accomplices use their voices to stand up and call out injustices, racism, and micro-aggressions in healthcare environments, pushing back against the western/white dominance of healthcare delivery [35,36].
Definitions and understandings of the roles of allies and accomplices have expanded and deepened since the recent emergence of the BlackLivesMatter movement in the USA [37]. Anecdotally, the terms ally and accomplice are reflective of the nuances of language that underpin these terms. Ally is a word with strong links to political positioning in times of war and conflict; for example, Australia has been a strategic ally in the western Alliance since World Wars I and II. Accomplices are generally understood to be assistants to those charged with a criminal offence. There has been a default deficit attitude (since colonization) of non-Indigenous/white society towards Indigenous Peoples and their culture, which has driven systemic over-incarceration of Indigenous Peoples in Australia. This deficit lens often equates Indigenous Peoples with criminality. Accomplice can, therefore, be an appropriate and accurate term for those who are genuinely committed to Indigenous Peoples’ empowerment, self-determination, and sovereignty.
Active accomplices have developed strong positive therapeutic relationships with Indigenous People, understanding that connection to Country and culture are crucial to health and well-being. Accomplices promote Indigenous patients, Elders, families, and communities as the ‘experts’ in Indigenous health and wellbeing, holding relational accountability for their words and actions [9,38]. They understand that relationships, Country, and culture are at the heart of Indigenous worldviews, and they respect and use culturally shaped communication styles, such as yarning and storytelling, to build trust and rapport in clinical settings [39].
As members of the dominant cultural group in healthcare, healthcare professionals can only become genuine and active allies and accomplices by using critical, deep self-reflection that acknowledges unconscious biases, assumptions, and attitudes. Aiming to reduce inevitable power imbalances in health care is at the core of the cultural safety framework, which is now required within everyday clinical practice for healthcare workers in Australia that must be free of racism [40]. Allies and accomplices value the unique and vital role of Aboriginal Health Workers/Practitioners within hospitals and mainstream healthcare services in creating culturally safer services [41]. Allies and accomplices can also reduce the burden placed on Aboriginal Liaison Officers (ALOs) within hospitals, who are frequently called on to advise and support non-Indigenous staff working with their people. These demands on an ALO’s time by non-Indigenous workers can create untenable workloads, leading to the ALO feeling overwhelmed and burnt out with disturbing frequency [42]. Having allies and accomplices in hospitals can therefore significantly reduce the ALOs workload, leaving them free to perform their primary role, providing culturally safe support, comfort, and guidance to Aboriginal people as they navigate the health system while in hospital.
Effective allies and accomplices know ‘their place’; that is, they know how to respectfully occupy the space between the Indigenous and non-Indigenous worlds within healthcare settings. They know when to ‘step up’ and speak out (e.g., calling out systemic or individual racism), when to ‘walk alongside’ Indigenous patients and colleagues (e.g., decolonising healthcare practice) and when to ‘step back’ (e.g., enabling Indigenous clients and colleague’s leadership, truth telling, self-determination, and governance).
As evidenced by the radio program and the voices of study participants, non-Indigenous staff working with Indigenous People at the Katherine Hospital clearly acted as effective allies. They have contributed to turning a previously culturally unsafe environment into a more culturally comfortable and safe environment for local Aboriginal People to access healthcare. Further, they have increased respect for and have developed an understanding of Aboriginal people’s strong connection to Country, including those kinship relations of cultural ways of being, knowing, and doing. Additionally, the inclusion of the cultural determinants of health into clinical practice supports the rights of Indigenous Australians [43] to practice their cultural beliefs, knowledges, and traditional healthcare practices that create culturally safe, clinically responsive care that is free of racism [18].
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