Professional Issues in Nursing and Specialisation

This document discusses the issues of cultural competence in the Australian healthcare system, specifically in relation to Indigenous Australians. It explores the lack of cultural competence and its impact on healthcare outcomes for Indigenous communities. The document also discusses the 'Closing the Gap' policy and its recommendations for improving cultural competence in healthcare organizations.

Running head: PROFESSIONAL ISSUES IN NURSING AND SPECIALISATION
PROFESSIONAL ISSUES IN NURSING AND SPECIALISATION
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Introduction
It is well know that Australia has a rich cultural heritage comprising of Indigenous as
well as Non-Indigenous populations. Indigenous Australians or Aboriginal and Torres Islander
(ATS) communities are regarded as the ‘first peoples’ of Australia due to them being the native
populations residing in the nation, since historical times prior to colonization by the Europeans
(Henderson et al., 2018). The infiltration of their native lands by Europeans resulted in an a
history of discrimination, exploitation and perceptions of stereotyping and stigma towards
Indigenous Australians which continue to exist in the nation even at present. In alignment to the
same, a key issue of concern which has continued to exist, especially during healthcare-
associated inquiry and help-seeking behaviour demonstrated by ATS communities is the lack of
cultural competence across healthcare organizations (Thai et al., 2018).
Individuals and groups belonging to diverse ethnic and cultural backgrounds like the ATS
communities of Australia, posses cultural, spiritual, healthcare and social principles, opinions,
ideas and preferences which are diverse from their non-Indigenous counterparts. The concept of
‘Cultural Competence’ implies the skills of understanding, empathizing and effectively
interacting with individuals belonging to diverse cultural groups and backgrounds (Ralph et al.,
2017). The administration of skills of cultural competence across providers of healthcare service
and healthcare professionals are of utmost importance to ensure positive health outcomes across
Indigenous individuals (McCalman et al., 2017). Despite the growing concern of the need for
cultural competence, insensitive and discrimination continue to exist towards ATS communities
in the Australian healthcare sectors, which contribute greatly to accessibility, affordability and
acceptability of such services and resources across Indigenous individuals, further resulting in

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discrepancies in positive health outcomes as compared to non-Indigenous groups (Gwynne,
Jeffries & Lincoln, 2019).
To combat such initiatives, the ‘Closing the Gap’ (CTG) policy initiative and national
strategy was undertaken by the Australian Government (Ibiebele et al., 2015). The following
report will hence focus upon the issues of cultural competency within the Australian healthcare
scenario, the key concepts underlying the issue, the specifications of the CTG policy and
possible recommendations for future improvement.
Discussion
Issues of Concern
According to the Federation of Ethnic Communities’ Council in Australia (2019),
‘Cultural Competence’ implies the capability of understanding, communicating and efficiently
interacting across individuals belonging to various diverse ethnic and cultural backgrounds. It is
defined as a collection of attitudes, behaviours and policies which harmonize and work in
synchronization within an organizational environment in order to make it well-equipped to deal
with diverse, cross-cultural situations.
According to Gwynne and Lincoln (2017), while interacting and working with
Indigenous Australians for the purpose of healthcare, there is a need for healthcare professionals
to consider the diverse cultural, ethnic and spiritual needs of individuals belonging to these
populations. Considering their historical experiences of exploitation as well as possession of a
rich cultural heritage diverse from non-Indigenous populations, ATS communities have unique
demands in healthcare which must be considered. Such diverse differences must be considered in
a culturally competent manner for the purpose of ensuring deliverance of holistic healthcare

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services to Indigenous Australians. In addition to diverse linguistic practices, as researched by Li
(2017), such populations generally regard healthcare organizations as places of death and an
isolation from their homelands during the end of their life will prevent their passing to the
‘Dreamtime’. The lack of empathy towards such sensitivities in healthcare organization, results
in a loss of eagerness and non-compliance towards seeking or adhering to treatment further
contributing to the rising discrepancies in mortality and life expectancy rates across ATS
communities as compared to non-Indigenous individuals, which were clearly demonstrated in the
CTG policy (Grant & Draper, 2018).
Additionally, as researched by Jennings, Bond and Hill (2018), a lack of cultural
competence in the form of racial discrimination, stigmatization and stereotyping continue to
prevail towards Indigenous Australians, which comprises of healthcare workers largely
perceiving such communities to be non-compliant and difficult to work or interact with.
Prevalence of such misperceptions and misbehaviours towards Indigenous Australians are
largely associated with negative health outcomes in terms of loss of physical, mental, social and
emotional wellbeing in these diverse populations. As reported by the Department of the Prime
Minister and the Cabinet (2014), the underlying pathways linking racial discrimination to poor
health outcomes include decreased access to essential needs such as healthcare, employment,
housing and education in Indigenous Australians which further increase the exposure to risk
factors like dysregulation of cortisol and associated stress. According to Paradies (2016), such
increased exposure increase the acquisition of conditions like anxiety, depression and metabolic
symptoms like cardiovascular diseases in Indigenous Australians and hence the alarming
disparities in rates of mortality and life expectancy. Chronic and long term exposure to emotional
and social abuses such racism have further been linked to life threatening conditions like

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inflammation, psychological distress, renal disorders and obesity, which further contribute to
reduced life expectancy rates across ATS communities. Hence, such prevailing concerns of
cultural incompetence and their associated long term impacts are what resulted in the
development of the CTG policy by the Australian government (Priest et al., 2017).
Key Concepts
The concepts which form the foundation for development of a culturally competent
framework and the lack of which raises perceptions of being discriminated and stigmatized
across Indigenous Australians is the four R’s framework, mainly: respect, relevance, reciprocity
and responsibility (Gould et al., 2015).
Respect: As researched by Gould et al., (2015), healthcare professionals must possess a
sense of respect for the diverse cultural and spiritual heritage possessed by ATS communities
as well as their unique social, familial and healthcare preferences. Social cohesion and a sense of
togetherness is an essential cultural need across Indigenous Australians and individuals
belonging to ATS communities. Additionally, according to Bailie et al., (2016), indigenous
Australians also feel the need to maintain a cultural distinctiveness which distinguishes them
from non-Indigenous communities. It is hence recommended that healthcare professionals
demonstrate this culturally competent sense of respect and understanding to such diverse cultural
needs of ATS communities. A lack of such form of understanding during the procurement of
healthcare interventions and services instils perception of mistrust, dissatisfaction and a sense of
one’s basic cultural background being disregarded among Indigenous Australians (Bailie et al.,
2016).
Relevance: According to Percival et al., (2016), a sense of relevance as per the five R’s
framework implies adoption of a culturally centred approach where healthcare professionals,

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during the process of recommending a healthcare intervention, must administer the same based
upon the unique cultural demands and preferences across ATS communities. More often than
not, popular or scientifically effective evidence based practices may not be compliant with the
diverse cultural, social and community needs of Indigenous Australian communities. Key
examples of the same can be specifically found in the case recommending preventive
interventions for addiction behaviours like smoking and alcohol in Indigenous communities for
whom such behaviours form an essential segment of family tradition. According to Hendrickx et
al., (2018), one of the major reasons which contribute to the lack of Indigenous engagement in
healthcare services and the associated adverse health consequences and disparities is the inability
and lack of concern across healthcare professionals to deliver a healthcare services and
interventions which are relevant and compliant to the needs of this community.
Reciprocity: As researched by Truong et al., (2017), key concept whose lack contributes
to the prevalent issue of cultural incompetence is reciprocity. The concept of reciprocity implies
the prevalence of equity and lack of discrimination across Indigenous Australians while seeking
or accessing healthcare services and educational resources. Indigenous Australians posses unique
linguistic and communication needs which often emerge as barriers to equitable access to
healthcare especially in the understanding of medical terms, available services and possible
consequences of each and every choice of healthcare services available to them. Further, as
researched by McGough, Wynaden and Wright (2018), cultural competence concepts of
reciprocity comprises of, not only the availability of healthcare interventions compliant to the
unique needs of the ATS communities but also the availability of healthcare informational
resources in languages and terms which could be understood by such communities. The lack of
linguistic understanding as per the unique languages used by ATS communities, results in

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negative perceptions associated with Indigenous Australians implying that present healthcare
services do not consider their diverse needs further resulting non-compliance to healthcare
treatments and long term negative health outcomes.
Responsibility: The culturally competent concept of responsibility implies the
prevalence of empathy, transparency and openness by healthcare professionals when
communicating with patients belonging to ATS communities. As discussed previously,
Indigenous Australians have encountered a history of discrimination and exploitation where their
voices have been continuously suppressed. Thus, Indigenous Australians have a right and an
intrinsic need to have the opportunity to voice their concerns and place their opinions during the
decision-making process in healthcare (Askew et al., 2017). It is recommended that healthcare
professionals adopt an culturally centered as well as patient centered approaches wherein along
with considering unique cultural needs, a direct interaction is also conducted where the
Indigenous patient is allowed to openly communicate his/her preferences, clear doubts as well as
share his or her opinions for any service or treatment provided. A lack usage of such concepts
continue to prevail in the Australian healthcare sector wherein the opinions of Indigenous
Australians are largely disregarded further resulting in discrimination, stigma and long term
negative health outcomes (Brown & Kritharides, 2017).
Policy
The prevalent social issues of lack of cultural competency, stigma and discrimination
towards Indigenous Australians belonging ATS communities have largely played a significant
role in the increased levels of disparities and inequities encountered by this population in the
availability and accessibility of healthcare services (Fowler et al., 2018). While the historical
atrocities and the diverse cultural needs possessed by these Indigenous Australians are already

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key contributors to existing disparities, prevalence of cultural insensitivities and lack of cultural
competence further increase long term burden of chronic diseases and loss of wellbeing across
this population. Hence, to combat the same, these issues contributed to the development of a
policy which is compliant to the unique needs of Indigenous Australians, known popularly as
‘Closing the Gap’ (CTG) (Markham, Jordan & Howard-Wagner, 2018).
CTG is a national initiative and policy strategy implemented by the government, with the
purpose of reducing prevalent disadvantages and the inequities encountered by ATS
communities in aspects of child mortality, life expectancy, educational achievement, positive
outcomes in employment and improved access to early childhood education. In terms of the
responsibilities of healthcare sectors, the CTG policy guides governments to work in
collaboration towards the improvement of equality in healthcare and associated positive health
outcomes such as rates of life expectancy across Indigenous Australians by the year 2030 (Luke,
2017).
To achieve such promising targets, the CTG policy recognizes the need to eradicate
healthcare disparities, ensure wellbeing and in the process, the importance of enhancing skills of
cultural competence across healthcare professionals. According to a recent report by the CTG, an
inability by state governments to meet the specified targets has been reported, mainly due to the
absence of a holistic healthcare intervention framework and lack of actively or directly involving
Indigenous Australians in the healthcare decision-making process by healthcare organizations
(Grant & Draper, 2018). Thus, to address the same, the CTG policy necessitates the presence of
Indigenous Health Liaison Officers (IHLOs) and the implementation of family meetings across
healthcare organizations while catering to patients belonging to ATS backgrounds.

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As researched by Kelly et al., (2018), IHLOs play a key role in ensuring the deliverance
of culturally competent healthcare across organizations by administering the responsibility of
being an intermediary or mediating personnel between patients and the healthcare professionals
allocated for the care of the cultural diverse patients. One of the major functions demonstrated by
IHLOs as per the CTG policy is to educate culturally diverse patients regarding available
healthcare serves as well as advocate for patients belonging to vulnerable populations or
minatory groups (McKenna et al., 2015). IHLOs also improve cultural competence in healthcare
organizations by implementing family centred approaches which comprises actively involving
and educating the families of culturally diverse patients in understanding available healthcare
services as well as providing them the opportunity to voice their doubts and concerns (Nyanga et
al., 2018).
An additional key role of IHLOs as per the CTG policy for the purpose of improving
cultural competence in healthcare organization includes understanding the diverse cultural needs
of Indigenous patients and communicating the same to associated healthcare providers in order
to improve their skills of cultural sensitivity as well as enlighten them on the need to administer
healthcare interventions compliant to the preferences of such patients (Wotherspoon & Williams,
2019). Such arrangements as per the CTG policy have been evidenced to not only improve
Indigenous patient involvement, engagement and decision-making in healthcare but also assists
in preventing stigmatization of such patients as being non-compliant and difficult to work with
by healthcare organizations (Katzenellenbogen et al., 2015).
Another key intervention of cultural competence stipulated by the CTG policy, is the
implementation of family meetings within the healthcare organization. It has been evidenced the
Indigenous patients arriving for therapy often hail from regional and remote communities with

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closely knit family ties and extensive family connections (Freeman et al., 2016). Considering the
same, Indigenous patients opting for intensive or critical treatments like surgeries often feel
alienated, isolated and fearful when kept in the foreign settings within healthcare organizations.
This lack of family support coupled with prevalent barriers in terms of language and cultural
preferences result in reduced compliance to treatment, faster rates of discharge and healthcare
relapses across culturally diverse patients belonging to ATS communities (Taylor et al., 2018).
In such situations, the presence of culturally competent arrangements such as family
meetings as per the CTG policy, contributes significantly to the improvement of patient
compliance to treatment, enhancement of health literacy and improved health outcomes and
perceptions of care across ATS patients and their family members alike (Dudgeon et al., 2016).
Family meetings comprise of family centred approaches where healthcare professionals must
actively communicate the healthcare needs and available healthcare services and interventions to
the patient as well as their families either via face-to-face conversation or via telehealth
mechanisms such as video conferences or telephonic conversations. Such culturally competent
interventions are beneficial since they administer feelings of security, comfort and belongingness
within both families and patients resulting in fulfilment of positive health outcomes and
improved compliance to healthcare services and interventions (Muir & Dean, 2017).
Additionally, the transmission of essential healthcare information, in a culturally appropriate
manner across a generation of family members instils perceptions of satisfaction and motivation
to engage in the suggested healthcare interventions within Indigenous Australians where they
feel that their needs have been respected and adhered to by organizations (Shahid et al., 2018).

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Future Recommendations
Despite the positive changes occurring as a result of implementation of the CTG policy,
there continues to remain discrepancies in terms of practice of cultural competence. According to
the cross sectional study conducted by Markwick et al., (2019), Indigenous Australians residing
in Victoria were estimated to encounter racial discrimination four times more as compared to
non-Indigenous populations. Similarly, the longitudinal analytical study by Shepherd et al.,
(2019), reported that Indigenous children and adults continue to encounter racial discrimination
across various aspects of employment and healthcare services. An issue report published as part
of the CTG policy evidenced that educational strategies of cultural competence, such as the
organization and staff training on the same, are not effective on their own to demonstrate
healthcare professional behaviour change, especially when delivered for short periods of time
without follow ups. An additional limitation investigated by this issue paper was the lack of
strategies of cultural tailoring and program transfer while delivering programs of cultural
competence across healthcare organizations (Bainbridge et al., 2015). This implies that only
must cultural competency programs and initiatives be tailor made and altered as per changing
healthcare needs of patients and unique requirements of various diseases, the same must also be
developed in collaboration with local Indigenous communities to ensure complete consideration
of all diverse requirements of such populations (Georges et al., 2017). Additional strategies
which have been recommended as beneficial for improving cultural competence is the educating
healthcare professionals on self-reflection and implementation of valid organizational
assessments for measurement of healthcare accessibility, quality of care, prevalence of perceived
discrimination and linguistic barriers (Saunders, 2015).

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Conclusion
This paper hence demonstrates the concerning areas and issues of cultural competence
which continue to existing in Australian Healthcare services, in response to Indigenous
Australians belonging to ATS communities. A lack of cultural competence comprises of more
than just prevalence of stigmatizing and discrimination. Insensitivities, incompetence and
discrimination towards the culturally diverse needs of ATS communities by healthcare
professionals results in loss of trust and satisfaction which further hinders Indigenous
accessibility towards such services and increased progression to the acquisition of negative
health outcomes and long term physiological and psychological diseases. To address these gaps
in healthcare and negative health outcomes within the ATS populations, the CTG policy was
developed. The availability of ILO’s and implementation of family centred approaches within
healthcare organizations as per the CTG policy has been proven to be beneficial in increasing
Indigenous Australians’ engagement in healthcare services. Despite the proven effectiveness,
healthcare discrepancies and the issues of concern continue to exist in the form of current
limitations in the CTG policy, mainly a lack of validated instruments and guideline assessing a
healthcare organization’s adherence to cultural competency as well as a lack of altering the
specifications of cultural competence educational programs based on the unique needs of various
sub-sections within healthcare services. Thus, in conclusion, future recommendations of cultural
tailoring and establishment of local Indigenous patients and health worker partnerships must be
considered as options for improvement.

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