Nurse Education Today 35 (2015) 461–467
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Nursing students' perspectives of the health and healthcare issues of Australian Indigenous people☆ Leanne Hunt ⁎, Lucie Ramjan, Glenda McDonald, Jane Koch, David Baird, Yenna Salamonson University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW 2751, Australia
a r t i c l e
i n f o
Article history: Accepted 20 November 2014 Keywords: Cultural competence Undergraduate nurse education Indigenous Australians Indigenous health Nursing students
s u m m a r y Background: Indigenous people are the most disadvantaged population within Australia with living conditions comparable to developing countries. The Bachelor of Nursing programme at the University of Western Sydney has embedded Indigenous health into the undergraduate teaching programme, with an expectation that students develop an awareness of Indigenous health and healthcare issues. Aim: To gain insight into students' perceptions of Indigenous people and whether the course learning and teaching strategies implemented improved students' learning outcomes and attitude towards Indigenous people and Indigenous health in Australia. Design: A mixed methods prospective survey design was chosen. Methods: Students enrolled in the Indigenous health subject in 2013 were invited to complete pre- and post-subject surveys that contained closed- and open-ended questions. Students' socio-demographic data was collected at baseline, but the ‘Attitude Toward Indigenous Australians’ (ATIA) scale, and the 3-item Knowledge, Interest and Confidence to nursing Australian Indigenous peoples scale were administered at both pre- and post-subject surveys. Results: 502 students completed the baseline survey and 249 students completed the follow-up survey. There was a statistically significant attitudinal change towards Indigenous Australians, measured by the ATIA scale, and participants' knowledge, intent to work with Indigenous Australians and confidence in caring for them increased significantly at follow-up. Based on the participants' responses to open-ended questions, four key themes emerged: a) understanding Indigenous history, culture and healthcare; b) development of cultural competence; c) enhanced respect for Indigenous Australians' culture and traditional practices; and d) enhanced awareness of the inherent disadvantages for Indigenous Australians in education and healthcare. There were no statistically significant socio-demographic group differences among those who commented on key themes. Conclusion: Addressing health inequalities for Indigenous Australians is paramount. Nurses need cultural awareness and sensitivity to deliver culturally appropriate healthcare in Australia. Crown Copyright © 2014 Published by Elsevier Ltd. All rights reserved.
Why Is This Research or Review Needed? • Culturally competent nursing care can have a positive impact on Indigenous Australians health outcomes • Indigenous Australians experience a higher burden of disease and higher mortality compared to non-Indigenous Australians
☆ Funding: This project received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. ⁎ Corresponding author. E-mail addresses: [email protected] (L. Hunt), [email protected] (L. Ramjan), [email protected] (G. McDonald), [email protected] (J. Koch), [email protected] (D. Baird), [email protected] (Y. Salamonson).
http://dx.doi.org/10.1016/j.nedt.2014.11.019 0260-6917/Crown Copyright © 2014 Published by Elsevier Ltd. All rights reserved.
• An awareness of the Indigenous health issues and cultural competence can improve the health outcomes of Indigenous peoples
What Are the Key Findings? • Supports the inclusion of Indigenous health and healthcare issues with a specific focus on cultural competence within undergraduate nursing programmes • Education relating to Indigenous history, culture and health, improves undergraduate nursing students' perceived confidence to work with Indigenous peoples • Challenging and reflecting on individual cultural beliefs assist the undergraduate nurse to reconcile differences and provides culturally competent nursing care
462
L. Hunt et al. / Nurse Education Today 35 (2015) 461–467
How Should the Findings Be Used to Influence Policy/Practice/ Research/Education? • Nursing education should take a comprehensive approach to support undergraduate nurses' understanding of Indigenous history, culture and health issues • Immersion in the Indigenous community through clinical placements provides students the ability to apply knowledge to real life experiences and transfer this experience to the clinical setting post registration. • Education can play an important role in establishing student nurses' confidence in caring for Indigenous Australians
Introduction Indigenous Australians are among the most vulnerable population in Australian society experiencing both social and health inequalities (Australian Institute of Health and Welfare, 2004). Across all measures of health, Indigenous Australians are over represented and experience a higher burden of disease and higher mortality at younger ages than non-Indigenous Australians (Australian Institute of Health and Welfare, 2012b). In fact, the health of non-Indigenous Australians has improved over the past 20 years while the Indigenous population's health status has remained largely unchanged (Australian Institute of Health and Welfare, 2012a). Disconcertingly, Australian Indigenous health has often been compared to the health standards of a third world country (Australian Human Rights Commission, 2010). There are suggestions that the poor health of Australia's Indigenous people affects the health of all Australians. The healthy migrant theory suggests that migrants arrive in developed countries with a superior standard of health compared to the general population of the host nation. However, over time the health of the migrants declines to match the general health of the host nation. Parallels can be made with the healthy migrant theory and Australians' general health and suggest that the poor health of Australia's Indigenous population also negatively impacts the wider community health (Harding, 2004; Wingate and Alexander, 2006). Nurses' practising cultural safety has a direct impact in reducing the health disparities experienced by Indigenous Australians (Lee et al., 2006; Durey, 2010). Therefore, it is crucial that Indigenous health is embedded into nursing practice as the effect on Indigenous health, morbidity and mortality are significant. This is supported by previous research that suggests restructuring nursing education to embed Indigenous perspectives into the curriculum and conduct clinical placements within Indigenous communities improves cultural sensitivity, changes attitudes towards Indigenous peoples, reduces racism and improves health outcomes for Indigenous Australians (Lee et al., 2006; Durey, 2010; Webster et al., 2010; Turale and Miller, 2006). Long term, the more culturally safe the health care system and its workers are, the more likely Indigenous people are to engage and use the services available. Early engagement in the health care system results in early health intervention strategies, prevention of illness and improved overall health outcomes for Indigenous Australians. Background Nurses can play a significant role in improving the health of Indigenous people and thus the wider community. The Nurses Code of Ethics and Nurses Code of Conduct require nurses to undertake patient advocacy and ensure that all patients are treated equally. The codes also require nurses to display a respect for culture, beliefs and traditions of all patients (Nursing and Midwifery Board Australia, 2006; Nursing and Midwifery Board of Australia, 2002). Specific to Indigenous health, the literature reports the benefits of cultural competence for improved
health outcomes in the Indigenous population (Durey, 2010; Liaw et al., 2011; Reibel and Walker, 2010; Stuart and Nielsen, 2011). To improve health outcomes requires an understanding of the reasons why there is an increased morbidity and mortality in Indigenous populations. Advocating for the health of Indigenous peoples not only involves knowledge but empathy for the basis for the disparities in health. Both may be fostered through undergraduate nursing programmes and positively impact in the long term on Indigenous health outcomes (Goold and Coulthard, 2009; Goold and Usher, 2006; Turale and Miller, 2006). There has been a move towards an increased Indigenous focus across nursing faculties by including Indigenous health and cultural competence in the undergraduate nursing student curriculum in an attempt to improve the health outcomes of Indigenous Australians (Nash et al., 2006; Ramsay and Kermode, 1997; Turale and Miller, 2006). The School of Nursing and Midwifery (SoNM) is a multi-campus school within a large university in the western region of Sydney. The student population is multicultural with 50% of students being born overseas across 16 different countries, with Asia being the birth place of 36% of these students (Salamonson et al., 2011). The Bachelor of Nursing programme has a dedicated unit exploring the factors effecting Australian Indigenous health in contemporary society. This dedicated unit of study consists of face to face tutorials and lectures. A range of topics are explored related to the historical, political and social aspects of Indigenous health. These aspects are taught in relation to the contemporary healthcare issues of cultural competence, cultural safety, racism, equity and access. This undergraduate programme is supported by the National Competency Standards for the Registered Nurse developed by the Nursing and Midwifery Board of Australia (Nursing and Midwifery Board Australia, 2010). The Study Aim The aim of this paper was to gain insight into students' perceptions of Indigenous peoples and to determine whether the course learning and teaching strategies improved students' learning outcomes and attitudes towards Indigenous people and Indigenous health issues in Australia. Design To meet the aims of this research, a mixed methods approach was chosen, with concurrent quantitative and qualitative data collection. This mixed methods design was chosen as it offers responses to variables such as rating of knowledge about the topic while exploring the in-depth perspectives of individuals. The qualitative component allowed participants to provide in-depth responses to open-ended questions that could then be compared to the quantitative data and ultimately enhanced the richness of the data. Study Setting and Participants The study was undertaken at a large multi-campus university in New South Wales, Australia, between March and June of 2013 in semester 1. Of the 944 students who enrolled in the unit, 502 (53.2%) completed the baseline survey. A total of 435 (86.7%) of those who completed the survey also provided consent for their completed survey to be linked to the follow-up survey. Of the 435 participants, 249 (57.2%) was available and completed the follow-up survey at the time when the follow-up survey was administered. The reduced participation rate in the follow-up survey may relate to the following factors: 1) participation in the study was voluntary and; 2) the unit of study did not have compulsory attendance requirements and as such, class participation rates declined during the semester.
L. Hunt et al. / Nurse Education Today 35 (2015) 461–467
Compared with nursing students who were enrolled in the unit, no group differences were observed between participants and nonparticipants in: a) age (mean: 29.0 years in participant versus 28.4 in non-participant, p = 0.308), b) gender (84.1% females versus 80.7%, p = 0.163), and c) country of birth (34.7% Australian-born versus 32.8%, p = 0.534). Data Collection Undergraduate nursing students who were enrolled in a unit of study related to health issues of Australian Indigenous People were invited to complete the surveys. They were briefed about the purpose of the study, which included gathering information to assist faculty to ensure the nursing curriculum was meeting students' needs for graduate practice. These students were also informed about the voluntary nature of their participation, and those who agreed to participate were asked to provide their student identification number so that their completed baseline survey could be linked to their follow-up survey that was administered at the end of the semester. The post-survey included openended questions related to the relevance and benefits of the unit and specifically asked: How do you think learning about Indigenous health in this unit will impact on your nursing care of Indigenous patients? Ethical Considerations Ethics approval was gained from the universities Human Research Ethics Committee. Participation in the study was voluntary. Information, including the purpose of the study and contact details, was provided to students in both the pre and post surveys. Consent was gained through students signing the student consent form.
463
scale (1 = ‘strongly disagree’ to 7 = ‘strongly agree’) consists of 12 forward and 8 reverse scored items. Following the appropriate recoding, responses to each item were aggregated with higher scores indicating greater negative attitudes about Indigenous Australians (Pedersen et al., 2004). This scale was reported to have high internal consistency (Cronbach's alpha = 0.92). In this study, the Cronbach's alpha calculated on data collected at baseline was 0.85 and 0.88 at follow-up. The KIC scale was an investigator-developed 3-item measure, used to measure students' self-reported knowledge, interest and confidence in working with Indigenous Australians, based on the key components that have been highlighted in the literature (NSW Department of Community Services, 2009; Pedersen et al., 2006). Each item is on an 11-point Likert scale (example: How confident are you of your ability to work with Australian Indigenous peoples? 0 = ‘Not at all confident’ and 10 = ‘Completely confident’). The KIC scale scores were calculated by aggregating the total scores of this 3-item measure. In this study, the Cronbach's alpha of this 3-item scale on data collected at baseline was 0.60 and data collected at follow-up was 0.68. The rigour of the qualitative data was reviewed in accordance to its authenticity, concreteness and actualisation. Open-ended questions were used as they are considered to be an apt method for obtaining an ‘authentic’ perspective of study participants' experiences and opinions (Seale and Silverman, 1997). An element of ‘concreteness’ was incorporated by students providing reflections of their learning experiences while being immersed and engaged within the immediate context of the unit. This in turn can potentially be applied to the development and actualisation of related educational frameworks and curricula (De Witt and Ploeg, 2006). The research team members discussed emerging themes regularly until consensus of interpretations was reached. Results
Data Analysis Socio-demographic, academic-related information and responses related to the two standardised scales were entered into IBM SPSS Statistics Version 22, and descriptive statistics were calculated. As none of the continuous variables were normally distributed, the Wilcoxon Signed Rank test was used to test for differences in ATIA and KIC scale scores between baseline and follow-up. A p value of b0.05 was considered statistically significant. The qualitative open-ended responses for each question were entered into an Excel spread sheet and analysed manually and thematically by two of the research team for recurring themes. Ethical Considerations By submitting the survey responses, students accepted that they had read the study information sheet and consented to participate in the study. Students were clearly informed that their participation in the survey was both anonymous and voluntary. The conduct of the study was approved by each of the relevant university Human Research Ethics Committees. Reliability and Rigour Although only slightly more than half of the student cohort enrolled in the unit of study participated in the study, no statistical significant differences were uncovered between participants and non-participants by age, gender or country of birth. Two standardised instruments, the 18-item “Attitude Toward Indigenous Australians” (ATIA) scale and the 3-item “Knowledge, Interest and Confidence” (KIC) scale, were included in the surveys. These were administered at baseline and at the end-of-semester follow-up. Items for the ATIA scale were developed and used to measure negative attitudes related to collective guilt, empathy and racial resentment about Indigenous Australians. This 18-item scale on a 7-point Likert
The characteristics of participants are summarised in Table 1. The mean age of participants at baseline was 27.2 years (median: 25.0, SD: 8.0) and ranged from 18 to 67. Nearly two-thirds (61.4%) was born outside Australia and about a similar percentage (63.5%) spoke other than English at home. Nearly one-quarter (23.7%) was international students. Only a small percentage (1.4%) of participants were Australian Indigenous people, similarly, only a small percentage (6.4%) had experience working with Australian Indigenous people. More than half (56.8%) of the participants obtained information about Australian Indigenous people through schools. Although most of the participants reported that they socialise with people outside their own cultural group (94.2%), less than one-quarter (22.7%) socialise with Australian Indigenous peoples. Quantitative Results: Comparisons of ATIA and KIC Scores at Baseline and Follow-up Fig. 1 shows the results of the change in negative attitude scores as measured by the ATIA scale, and the change in knowledge, interest and confidence scores as measured by the KIC scale. There was a statistically significant decrease (50.6 to 49.1, p = 0.017) in scores on negative attitudes towards Australian Indigenous peoples, and there was a statistically significant increase (15.5 to 19.1, p b 0.001) in scores on knowledge, interest and confidence in working with Australian Indigenous peoples. Qualitative Findings Four major themes emerged from the analysis of the qualitative responses to the open-ended questions. These themes included: 1) understanding Indigenous history, culture and healthcare; 2) development of cultural competence; 3) enhanced respect for Indigenous Australians' culture and traditional practices; and 4) enhanced awareness
464
L. Hunt et al. / Nurse Education Today 35 (2015) 461–467
Table 1 Characteristics of participants at baseline (n = 502). Variable Age, mean (SD) median years (range: 18 to 57 years) 27.2 (8.0) 25.0 Sex, n (%) Male 84 (16.7) Female 419 (83.3) Country of birth, n (%) Australia 194 (38.6) Born outside Australia 309 (61.4) Language spoken at home, n (%) English 183 (36.5) Other than English 102 (20.3) Both English and other than English 217 (43.2) Enrolment category, n (%) Domestic 383 (76.3) International 119 (23.7) Origin: Australian Indigenous people, n (%) Yes 7 (1.4) No 495 (98.6) Experience working with Australian Indigenous peoples, n (%) Yes 32 (6.4) No 470 (93.6) Sources of information about Australian Indigenous peoples, n (%) Media 163 (32.4) School 285 (56.8) Other 55 (10.8) Socialise with people outside participants' cultural group, n (%) Yes 473 (94.2) No 29 (5.8) Socialise with Australian Indigenous peoples, n (%) Yes 114 (22.7) No 388 (77.3) Awareness of health issues of the Australian Indigenous peoples, n (%) Yes 78 (15.5) No 424 (84.5)
of the inherent health and educational disadvantages for Indigenous Australians. All participants were identified by number.
of the health issues affecting Australian Indigenous peoples. Following this unit they expressed a greater awareness of the individual, in the context of their roles and responsibilities within Indigenous communities. Some students reported that the unit had provided them with insights into Indigenous peoples' cultural beliefs and values and their perceptions of health and illness. Students appreciated learning about significant events across the lifespan for Indigenous peoples, such as birth and death, proposing this knowledge would enable them to be more responsive to their clients' needs. Responses indicated an increased awareness of the cultural aspects of health maintenance, traditional practices and health beliefs of Indigenous communities that could influence Indigenous peoples' attitudes and distrust towards Western, biomedical modalities of health care. This is illustrated by a participant in the following extract: “Helps me on how to interact with Indigenous people. Learn why they are often hesitant to approach health care service[s]” (76). “More recognition of the importance of family and community during their treatment/healing/death process, and the way in which Indigenous peoples may perceive western medical assistance” (249).
“I'll be more concerned with the words I say and questions I ask. Knowledge of cultural aspects of Indigenous people and their perception of wellbeing will allow me to provide the best care for these patients” (504). Poignantly some students realised that their preconceptions were limited by their environment and upbringing. Interestingly these comments were expressed by both international and domestic students. Engagement in the unit broadened their knowledge and perspectives of Aboriginal culture and healthcare. “I was raised in a typical Australian (white) setting in a country town that had little to no cultural diversity. I had a small amount of prior knowledge …only had contact with Aboriginal peoples in a tourist type setting…” (712).
Understanding Indigenous History, Culture and Healthcare Indigenous History Participants reported an increased knowledge and understanding of Indigenous history and the impact of past events and government policies on the health status of Indigenous Australians. Students commented that they gained a greater appreciation of the injustices of the past which increased their awareness of the health disparities and needs of Indigenous Australians: “Because I believe to be able to achieve good health outcomes for Aboriginal people, you need to know their history and culture” (490). These qualitative insights which suggest an increased knowledge base align with the quantitative results. In some cases, the learning experiences gained in the unit served as an awakening of students' understanding of the significance of history in the lives of Indigenous people. For some students this prompted a change in attitude and a desire to look for opportunities to interact and work with Indigenous Australians. This is further supported by the quantitative data which reported an increased interest among participants to work in this field of nursing.
“Though I belong to an Indigenous community overseas, having this unit prompted me to self-reflect and understand better about Indigenous communities” (215).
“I had no real understanding or appreciation of their past injustices and the hardship they face today. I have discovered passion in myself to do what I can to help the Aboriginal people as a nurse and will be looking for work in this field once I am registered” (712).
Indigenous Culture and Healthcare Participants illustrated broadened perspectives of Aboriginal people, their culture and healthcare as a result of the unit of study. Specifically, 84.5% of participants indicated prior to this unit, they had no awareness
Fig. 1. Comparison of baseline and follow-up scores: a) attitude towards Indigenous Australians; and b) knowledge, interest & confidence scores.
L. Hunt et al. / Nurse Education Today 35 (2015) 461–467
Development of Cultural Competence A key element of cultural competence entails engagement (Duke et al., 2009). Cultural competence is not solely the recognition of difference between cultures; it is the integration of culture into the provision of nursing care (Universities Australia, 2011). It is noteworthy that while 94.2% of participants socialised with people outside their own cultural group, only 22.7% socialised with Australian Indigenous peoples. Although the quantitative data showed that negative attitudes towards Indigenous Australians improved, the fact that these participants had limited contact and/or exposure with Indigenous peoples and communities may explain why the change was not greater. On a positive note, the participants identified that they had gained insights into developing their cultural competence and would apply these strategies in the provision of effective nursing care to Indigenous peoples. They recognised the importance of being cognisant of one's own cultural values as well as those of others. They explained that as a result of improved cultural competence they believed they would be more likely to provide culturally sensitive and safe nursing care. “Knowing other values helps a lot in rendering an effective nursing care because of awareness of our differences” (73).
“It will help me to be more culturally competent and safe in my nursing practice” (451). As part of developing cultural competence, participants reported improved communication skills and enhanced perceived confidence to interact with Indigenous peoples. This finding of increased confidence correlates with the quantitative results. Participants expressed improved knowledge and skills in therapeutic communication as a result of the unit. These skills included an improved perceived ability to build rapport and therapeutic relationships with Indigenous peoples and then implement appropriate strategies for care.
465
“Being a nurse, we always have to work in a multicultural environment. This unit taught how to work in such environment and respect other culture” (552).
“Because nursing is not just a profession [about] caring and helping others to have… better health but it is also a means of respecting and accepting others culture and beliefs” (830). It is enlightening that a participant has come to the realisation that the unit has prepared students to be cognisant of the impact of their behaviours on Indigenous patients, acknowledging that culturally insensitive practices can cause humiliation and embarrassment. “Future nurses will already know how to take care of the Indigenous patients in such a way that they will not be ashamed and therefore respected” (105).
Enhanced Awareness of the Inherent Health and Educational Disadvantages for Indigenous Australians The final theme that emerged revolved around an enhanced awareness of the inherent challenges for Indigenous Australians. These challenges focussed on education and the social determinants of health. Students developed their understanding of the effects of colonisation upon the health status of Indigenous peoples in the contemporary context, such as the higher mortality and morbidity rates. Students felt they were better informed about the health and educational factors that underpin the Closing the Gap policy. In addition, some participants linked this awareness to the provision of culturally competent and safe nursing care. “I found this unit good to get to know the gap for health issues and understand the history behind the choices they make” (145).
“This will make me more comfortable and knowledgeable in dealing with Indigenous patients” (84).
“I will be able to empathise with the patient and avoid misconceptions and discrimination in the giving of care” (101).
“It will make me more confident to deal with patients from Indigenous group” (290).
“Huge impact because before this unit I did not have a good understanding of all the issues involved in the actual life of the Aboriginal people today” (357).
“Understanding health problems of Indigenous Australians and where these problems come from is imperative for providing the best quality culturally competent care” (573).
“Knowing how to build rapport to build a positive relationship” (30). Discussion Enhanced Respect for Indigenous Australians' Culture and Traditional Practices Consequently some participants described how an increased understanding of the richness of Indigenous culture and traditional practices enhanced respect. Students were exposed to the positive aspects of the culture, opening their eyes to the resiliency of Indigenous peoples despite the evident adversities they continue to face. A significant attitudinal change and positive affirmation were acknowledged by a number of participants. Furthermore they reported that their learning experiences in the unit reinforced their professional requirement to respect and value cultural diversity in the provision of therapeutic care. “The unit is valuable to nursing as it gives an insight into how Indigenous people are in regards to health and how nurses should respect and treat Aboriginal Australians” (419).
This study has revealed that completing a unit of study solely dedicated to Indigenous history, culture and health, improved negative attitudes, increased nursing students' overall confidence, desire to work with and their knowledge of the issues facing Indigenous peoples. It is not surprising that education has played a major role in challenging negative attitudes, assisting in breaking down misconceptions and stereotypes and increasing nursing students' knowledge and respect for a culture that has endured significant adversities. As Goold and Usher (2006, p. 290) point out: “A lack of first-hand information provides fertile ground for simplistic or false perceptions as most non-Indigenous nurses have had no contact with, or knowledge of, the Australian Indigenous person or their history…”. This is confirmed by our study, which indicated 77.3% did not socialise with Indigenous people. Their knowledge about Indigenous history, culture and healthcare was gained from prior school learning or the media, which may perpetuate negative stereotypes.
466
L. Hunt et al. / Nurse Education Today 35 (2015) 461–467
Our findings support others in that a greater awareness and understanding of Indigenous history, Aboriginal protocols, culture and healthcare issues (including the inherent health and educational disadvantages) better prepares nursing students for the clinical environment and for deliverance of culturally-sensitive healthcare (Durey, 2010; Fredericks, 2006; Goold and Usher, 2006). While it may be difficult for some non-Indigenous students to hear about, reflect on and accept the injustices of the past (Durey, 2010), having an awareness of how oppression, racism, marginalisation and disempowerment of a cultural group and how it can have significant ramifications for quality patient care, is paramount. As others have advocated and as this unit of study has done, when educating others about Australian Indigenous peoples, nursing students need to be provided the opportunity to reflect on their own beliefs and culture (which may be influenced by ingrained beliefs and biases about other cultures) and be challenged in a safe environment (Durey, 2010). Durey (2010) insists that it is not enough to provide a ‘piecemeal’ approach to cultural education, rather prejudices and stereotypical misconceptions need to be challenged openly. In this way issues can be addressed and reconciled so that nursing students' practices embrace the importance of ‘respecting the difference’ (NSW Health, 2011). Similarly, providing sufficient depth to cultural learning experiences has implications for increasing students' confidence in their own communication skills in the clinical context. Students in this study indicated that their initial unease about communicating effectively with Indigenous clients was dispelled over the course of the unit, after increasing their knowledge of Indigenous cultural practices and health beliefs. The beneficial outcomes in this regard indicated that students may translate increased knowledge and understanding about Indigenous populations into nursing action, through greater confidence in communicating with clients appropriately for effective healthcare. As previously outlined, professional communication skills are a primary action of culturally competent nursing care (Thackrah et al., 2011). Providing the means for nursing students to be confident in engaging in safe and effective clinical interactions with their Indigenous clients in the future, as occurred in this unit, is therefore integral to improving Indigenous peoples' health status more broadly. It is timely to note, as others have done in previous literature, that such education needs to be sustained and consistent throughout nursing courses for meaningful development of cultural competence (Durey, 2010). Participant perceptions revealed that the unit had generated student interest in the field of Indigenous health, sparking in some a desire to work with Indigenous people and communities in the future. Campinha-Bacote (2008) proposed that possessing cultural desire, or personal willingness, was a crucial foundation for beginning the process of developing cultural competence. Central constructs such as caring, social justice and humility were considered essential for authentic engagement with this process. Several participants in this study reported similar personal responses to the learning experiences of this unit. Their cultural desire was characterised by burgeoning interest, passion and genuine openness to learning about oneself and others. Some participants indicated a new sense of purpose in embarking on a nursing career that incorporated culturally competent care of Indigenous peoples. The findings of this study confirmed the role of cultural desire in student engagement with becoming culturally competent. They also support the possibility of fostering attitudinal changes within the affective domain through cultural learning experiences. Mixed methods evaluations, such as this study, shed further light on the effect of cultural education on student attitudes and aspirations. However, as indicated by the findings, the completion of a single unit of study is unlikely to directly lead to cultural competence. Williamson and Harrison (2010) warn against a ‘cookbook’ approach to culturally appropriate care. Such can lead to stereotyping that is counterproductive and also impacts on the competently safe care of individuals (Alexis, 2011; Durey, 2010). Furthermore, a focus on cognitive aspects such as traditions, values and culture is insufficient as “it fails to take
into account broader, social, political and economic factors which affect health” (Williamson and Harrison, 2010, p. 765). For example, the political underpinnings of Indigenous health in New Zealand are notably different to those affecting Australia's Indigenous population. Despite these reservations, the improved communication and confidence reported by respondents in this study are commendable. The acquisition of new or revised knowledge should be interpreted positively. As a starting point, it should be built on. As previously noted, engagement is a key element (Duke et al., 2009). Personal contact with Indigenous Australians has been shown to be “a statistically significant factor of appropriate post-unit attitudes” (Ramsay and Kermode, 1997, p. 38) concerning Indigenous health. In addition to this, other considerations to enhance the culturallycompetent relevance of this unit involve the inclusion of Indigenous community members as culturally-specific educators (Nguyen and Gardiner, 2008), increased interaction with Indigenous people, especially in a clinical setting (Goold and Usher, 2006), and greater emphasis on personal reflection (Williamson and Harrison, 2010). Moreover, as providing culturally appropriate nursing care is a daily reality that affects all levels of nurses (Williamson and Harrison, 2010), a further consideration is the embedding of cultural competence and safety education in postgraduate education. The encouragement of a transformational shift to cultural safety is facilitated by culturally-informed nurse leaders (Duke et al., 2009; Goold and Coulthard, 2009). Limitations There were limitations to this study. The number of students enrolled in the unit and eligible to participate was 944. Student's participation in the baseline and follow-up surveys varied. The baseline survey recruited 502 participants this decreased to 249 participants in the follow-up survey. Due to the small participation rates the results may not be reflective of the learning of the entire cohort of students. Due to the limited participants the results may not be reflective of all students learning outcomes and attitudes towards Indigenous people and Indigenous health issues in Australia. Conclusion The findings of this study are well supported in the literature. If health care professionals are to make an impact in the area of Indigenous health and work towards “Closing the Gap”, Indigenous health issues, cultural competence and cultural safety should form an integral part of undergraduate nursing curriculum. Immersion in Indigenous related placements and Indigenous lecturers to provide real-life experiences is necessary to facilitate this. There are multiple barriers to this proposal. Financial constraints, staff resources, equitable experiences for students, student numbers, the clinical calendar, and the ability of the lecturer to attend multiple campuses are just some of the constraints. Possible ways forward include expanding the availability of Indigenous health placements and the use of the blended learning environment to enhance the students' experience and knowledge of Indigenous health issues. References Alexis, O., 2011. Health and cultural sensitivity in a diversifying society. Br. J. Healthc. Assist. 5 (6), 297–298. Australian Human Rights Commission, 2010. Social justice report: Aboriginal and Torres Strait Islander Social Justice Commissioner. Retrieved 22 May, 2014, from. https:// www.humanrights.gov.au/sites/default/files/content/social_justice/sj_report/ sjreport10/pdf/sjr2010_full.pdf. Australian Institute of Health and Welfare, 2004. Health inequalities in Australia: mortality. Retrieved 22 May, 2014, from. http://www.aihw.gov.au/publications/phe/hiam/ hiam.pdf. Australian Institute of Health and Welfare, 2012a. Australian trends in life expectancy. Retrieved 22 May, 2014, from. http://www.aihw.gov.au/australian-trends-in-lifeexpectancy/.
L. Hunt et al. / Nurse Education Today 35 (2015) 461–467 Australian Institute of Health and Welfare, 2012b. The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples. Retrieved 22 May, 2014, from. http:// aihw.gov.au/mortality-indigenous/. Campinha-Bacote, J., 2008. Cultural desire: caught or taught? Contemp. Nurse 28, 141–148. De Witt, L., Ploeg, J., 2006. Critical appraisal of rigour in interpretive phenomenological nursing research. J. Adv. Nurs. 55 (2), 215–229. Duke, J., Connor, M., McEldowney, R., 2009. Becoming a culturally competent health practitioner in the delivery of culturally safe care: a process oriented approach. J. Cult. Divers. 16 (2), 40–49. Durey, A., 2010. Reducing racism in Aboriginal health care in Australia: where does culture education fit in? Aust. N. Z. J. Public Health 34 (S1), 87–92. Fredericks, B., 2006. Which way? Educating for nursing Aboriginal and Torres Strait Islander peoples. Contemp. Nurse 23 (1), 87–99. Goold, S., Coulthard, R., 2009. CATSIN welcomes national uniformity in nursing education. Aust. Nurs. J. 16 (8), 37. Goold, S.S., Usher, K., 2006. Meeting the health needs of Indigenous people: how is nursing education meeting the challenge? Contemp. Nurse 22 (2), 288–295. Harding, S., 2004. Mortality of migrants from the Caribbean to England and Wales: effect of duration of residence. Int. J. Epidemiol. 33 (2), 382–386. Lee, C., Anderson, M., Hill, P., 2006. Cultural sensitivity education for nurses: a pilot study. J. Contin. Educ. Nurs. 37 (3), 137–141. Liaw, S., Lau, P., Pyett, P., Furler, J., Burchill, M., Rowley, K., et al., 2011. Successful chronic disease care for Aboriginal Australians requires cultural competence. Aust. N. Z. J. Public Health 35 (3), 238–248. Nash, R., Meiklejohn, B., Sacre, S., 2006. The Yapunyah project: embedding Aboriginal and Torres Strait Islander perspectives in the nursing curriculum. Contemp. Nurse 22 (2), 296–316. Nguyen, H.T., Gardiner, A., 2008. Indigenous community members as teachers of indigenous health. Aust. Fam. Physician 37 (12), 1019–1031. NSW Department of Community Services, 2009. Working with Aboriginal people and communities: a practice resource. Retrieved 4 November, 2014, from. http://www. community.nsw.gov.au/docswr/_assets/main/documents/working_with_aboriginal. pdf. NSW Health, 2011. Respecting the difference: an Aboriginal cultural training framework for NSW Health. Policy document PD2011_069. Retrieved 22 May, 2014, from. http://www0.health.nsw.gov.au/policies/pd/2011/pdf/PD2011_069.pdf. Nursing and Midwifery Board Australia, 2006. Code of professional conduct for nurses in Australia. Retrieved 3 December, 2013, from. http://www.nursingmidwiferyboard. gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx#codeofethics.
467
Nursing and Midwifery Board Australia, 2010. National competency standards for the registered nurse. Retrieved 22 May, 2014, from. http://www.nursingmidwiferyboard. gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx. Nursing and Midwifery Board of Australia, 2002. Code of ethics for nurses in Australia. Retrieved 3 December, 2013, from. http://www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements.aspx. Pedersen, A., Beven, J., Griffiths, B., 2004. Attitudes towards Indigenous Australians: the role of empathy and guilt. J. Community Appl. Soc. Psychol. 14, 233–249. Pedersen, A., Dudgeon, P., Watt, S., Griffiths, B., 2006. Attitudes toward indigenous Australians: the issue of “special treatment”. Aust. Psychol. 41 (2), 85–94. Ramsay, L., Kermode, S., 1997. Nurses facilitating reconciliation through education. Aust. J. Adv. Nurs. 15 (1), 32–39. Reibel, T., Walker, R., 2010. Antenatal services for Aboriginal women: the relevance of cultural competence. Qual. Prim. Care 18, 65–74. Salamonson, Y., Andrew, S., Clauson, J., Jacobs, S., Cleary, M., Jackson, D., 2011. Linguistic diversity as sociodemographic predictor of nursing program progression and completion. Contemp. Nurse 38 (1–2), 84–93. Seale, C., Silverman, D., 1997. Ensuring rigour in qualitative research. Eur. J. Pub. Health 7 (4), 379–384. Stuart, L., Nielsen, A., 2011. Two Aboriginal registered nurses show us why black nurses caring for black patients is good medicine. Contemp. Nurse 37 (1), 96–101. Thackrah, R., Scott, K., Winch, J., 2011. Indigenous Australian Health and Cultures: An Introduction for Health Professionals. Frenches Forest, Pearson Australia. Turale, S., Miller, M., 2006. Improving the health of Indigenous Australians: reforms in nursing education. An opinion piece of international interest. Int. Nurs. Rev. 53 (3), 171–177. Universities Australia, 2011. National Best Practice Framework for Indigenous Cultural Competency in Australian Universities. Department of Education, Employment and Workplace Relations, Canberra. Webster, S., Lopez, V., Allnut, J., Clague, L., Jones, D., Bennett, P., 2010. Undergraduate nursing students' experiences in a rural clinical placement. Aust. J. Rural Health 18, 194–198. Williamson, M., Harrison, L., 2010. Providing culturally appropriate care: a literature review. Int. J. Nurs. Stud. 47 (6), 761–769. Wingate, M., Alexander, G., 2006. The healthy migrant theory: variations in pregnancy outcomes among US born migrants. Soc. Sci. Med. 62, 491–498.
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Nursing students' perspectives of the health and healthcare issues of Australian Indigenous people☆ Leanne Hunt ⁎, Lucie Ramjan, Glenda McDonald, Jane Koch, David Baird, Yenna Salamonson University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW 2751, Australia
a r t i c l e
i n f o
Article history: Accepted 20 November 2014 Keywords: Cultural competence Undergraduate nurse education Indigenous Australians Indigenous health Nursing students
s u m m a r y Background: Indigenous people are the most disadvantaged population within Australia with living conditions comparable to developing countries. The Bachelor of Nursing programme at the University of Western Sydney has embedded Indigenous health into the undergraduate teaching programme, with an expectation that students develop an awareness of Indigenous health and healthcare issues. Aim: To gain insight into students' perceptions of Indigenous people and whether the course learning and teaching strategies implemented improved students' learning outcomes and attitude towards Indigenous people and Indigenous health in Australia. Design: A mixed methods prospective survey design was chosen. Methods: Students enrolled in the Indigenous health subject in 2013 were invited to complete pre- and post-subject surveys that contained closed- and open-ended questions. Students' socio-demographic data was collected at baseline, but the ‘Attitude Toward Indigenous Australians’ (ATIA) scale, and the 3-item Knowledge, Interest and Confidence to nursing Australian Indigenous peoples scale were administered at both pre- and post-subject surveys. Results: 502 students completed the baseline survey and 249 students completed the follow-up survey. There was a statistically significant attitudinal change towards Indigenous Australians, measured by the ATIA scale, and participants' knowledge, intent to work with Indigenous Australians and confidence in caring for them increased significantly at follow-up. Based on the participants' responses to open-ended questions, four key themes emerged: a) understanding Indigenous history, culture and healthcare; b) development of cultural competence; c) enhanced respect for Indigenous Australians' culture and traditional practices; and d) enhanced awareness of the inherent disadvantages for Indigenous Australians in education and healthcare. There were no statistically significant socio-demographic group differences among those who commented on key themes. Conclusion: Addressing health inequalities for Indigenous Australians is paramount. Nurses need cultural awareness and sensitivity to deliver culturally appropriate healthcare in Australia. Crown Copyright © 2014 Published by Elsevier Ltd. All rights reserved.
Why Is This Research or Review Needed? • Culturally competent nursing care can have a positive impact on Indigenous Australians health outcomes • Indigenous Australians experience a higher burden of disease and higher mortality compared to non-Indigenous Australians
☆ Funding: This project received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. ⁎ Corresponding author. E-mail addresses: [email protected] (L. Hunt), [email protected] (L. Ramjan), [email protected] (G. McDonald), [email protected] (J. Koch), [email protected] (D. Baird), [email protected] (Y. Salamonson).
http://dx.doi.org/10.1016/j.nedt.2014.11.019 0260-6917/Crown Copyright © 2014 Published by Elsevier Ltd. All rights reserved.
• An awareness of the Indigenous health issues and cultural competence can improve the health outcomes of Indigenous peoples
What Are the Key Findings? • Supports the inclusion of Indigenous health and healthcare issues with a specific focus on cultural competence within undergraduate nursing programmes • Education relating to Indigenous history, culture and health, improves undergraduate nursing students' perceived confidence to work with Indigenous peoples • Challenging and reflecting on individual cultural beliefs assist the undergraduate nurse to reconcile differences and provides culturally competent nursing care
462
L. Hunt et al. / Nurse Education Today 35 (2015) 461–467
How Should the Findings Be Used to Influence Policy/Practice/ Research/Education? • Nursing education should take a comprehensive approach to support undergraduate nurses' understanding of Indigenous history, culture and health issues • Immersion in the Indigenous community through clinical placements provides students the ability to apply knowledge to real life experiences and transfer this experience to the clinical setting post registration. • Education can play an important role in establishing student nurses' confidence in caring for Indigenous Australians
Introduction Indigenous Australians are among the most vulnerable population in Australian society experiencing both social and health inequalities (Australian Institute of Health and Welfare, 2004). Across all measures of health, Indigenous Australians are over represented and experience a higher burden of disease and higher mortality at younger ages than non-Indigenous Australians (Australian Institute of Health and Welfare, 2012b). In fact, the health of non-Indigenous Australians has improved over the past 20 years while the Indigenous population's health status has remained largely unchanged (Australian Institute of Health and Welfare, 2012a). Disconcertingly, Australian Indigenous health has often been compared to the health standards of a third world country (Australian Human Rights Commission, 2010). There are suggestions that the poor health of Australia's Indigenous people affects the health of all Australians. The healthy migrant theory suggests that migrants arrive in developed countries with a superior standard of health compared to the general population of the host nation. However, over time the health of the migrants declines to match the general health of the host nation. Parallels can be made with the healthy migrant theory and Australians' general health and suggest that the poor health of Australia's Indigenous population also negatively impacts the wider community health (Harding, 2004; Wingate and Alexander, 2006). Nurses' practising cultural safety has a direct impact in reducing the health disparities experienced by Indigenous Australians (Lee et al., 2006; Durey, 2010). Therefore, it is crucial that Indigenous health is embedded into nursing practice as the effect on Indigenous health, morbidity and mortality are significant. This is supported by previous research that suggests restructuring nursing education to embed Indigenous perspectives into the curriculum and conduct clinical placements within Indigenous communities improves cultural sensitivity, changes attitudes towards Indigenous peoples, reduces racism and improves health outcomes for Indigenous Australians (Lee et al., 2006; Durey, 2010; Webster et al., 2010; Turale and Miller, 2006). Long term, the more culturally safe the health care system and its workers are, the more likely Indigenous people are to engage and use the services available. Early engagement in the health care system results in early health intervention strategies, prevention of illness and improved overall health outcomes for Indigenous Australians. Background Nurses can play a significant role in improving the health of Indigenous people and thus the wider community. The Nurses Code of Ethics and Nurses Code of Conduct require nurses to undertake patient advocacy and ensure that all patients are treated equally. The codes also require nurses to display a respect for culture, beliefs and traditions of all patients (Nursing and Midwifery Board Australia, 2006; Nursing and Midwifery Board of Australia, 2002). Specific to Indigenous health, the literature reports the benefits of cultural competence for improved
health outcomes in the Indigenous population (Durey, 2010; Liaw et al., 2011; Reibel and Walker, 2010; Stuart and Nielsen, 2011). To improve health outcomes requires an understanding of the reasons why there is an increased morbidity and mortality in Indigenous populations. Advocating for the health of Indigenous peoples not only involves knowledge but empathy for the basis for the disparities in health. Both may be fostered through undergraduate nursing programmes and positively impact in the long term on Indigenous health outcomes (Goold and Coulthard, 2009; Goold and Usher, 2006; Turale and Miller, 2006). There has been a move towards an increased Indigenous focus across nursing faculties by including Indigenous health and cultural competence in the undergraduate nursing student curriculum in an attempt to improve the health outcomes of Indigenous Australians (Nash et al., 2006; Ramsay and Kermode, 1997; Turale and Miller, 2006). The School of Nursing and Midwifery (SoNM) is a multi-campus school within a large university in the western region of Sydney. The student population is multicultural with 50% of students being born overseas across 16 different countries, with Asia being the birth place of 36% of these students (Salamonson et al., 2011). The Bachelor of Nursing programme has a dedicated unit exploring the factors effecting Australian Indigenous health in contemporary society. This dedicated unit of study consists of face to face tutorials and lectures. A range of topics are explored related to the historical, political and social aspects of Indigenous health. These aspects are taught in relation to the contemporary healthcare issues of cultural competence, cultural safety, racism, equity and access. This undergraduate programme is supported by the National Competency Standards for the Registered Nurse developed by the Nursing and Midwifery Board of Australia (Nursing and Midwifery Board Australia, 2010). The Study Aim The aim of this paper was to gain insight into students' perceptions of Indigenous peoples and to determine whether the course learning and teaching strategies improved students' learning outcomes and attitudes towards Indigenous people and Indigenous health issues in Australia. Design To meet the aims of this research, a mixed methods approach was chosen, with concurrent quantitative and qualitative data collection. This mixed methods design was chosen as it offers responses to variables such as rating of knowledge about the topic while exploring the in-depth perspectives of individuals. The qualitative component allowed participants to provide in-depth responses to open-ended questions that could then be compared to the quantitative data and ultimately enhanced the richness of the data. Study Setting and Participants The study was undertaken at a large multi-campus university in New South Wales, Australia, between March and June of 2013 in semester 1. Of the 944 students who enrolled in the unit, 502 (53.2%) completed the baseline survey. A total of 435 (86.7%) of those who completed the survey also provided consent for their completed survey to be linked to the follow-up survey. Of the 435 participants, 249 (57.2%) was available and completed the follow-up survey at the time when the follow-up survey was administered. The reduced participation rate in the follow-up survey may relate to the following factors: 1) participation in the study was voluntary and; 2) the unit of study did not have compulsory attendance requirements and as such, class participation rates declined during the semester.
L. Hunt et al. / Nurse Education Today 35 (2015) 461–467
Compared with nursing students who were enrolled in the unit, no group differences were observed between participants and nonparticipants in: a) age (mean: 29.0 years in participant versus 28.4 in non-participant, p = 0.308), b) gender (84.1% females versus 80.7%, p = 0.163), and c) country of birth (34.7% Australian-born versus 32.8%, p = 0.534). Data Collection Undergraduate nursing students who were enrolled in a unit of study related to health issues of Australian Indigenous People were invited to complete the surveys. They were briefed about the purpose of the study, which included gathering information to assist faculty to ensure the nursing curriculum was meeting students' needs for graduate practice. These students were also informed about the voluntary nature of their participation, and those who agreed to participate were asked to provide their student identification number so that their completed baseline survey could be linked to their follow-up survey that was administered at the end of the semester. The post-survey included openended questions related to the relevance and benefits of the unit and specifically asked: How do you think learning about Indigenous health in this unit will impact on your nursing care of Indigenous patients? Ethical Considerations Ethics approval was gained from the universities Human Research Ethics Committee. Participation in the study was voluntary. Information, including the purpose of the study and contact details, was provided to students in both the pre and post surveys. Consent was gained through students signing the student consent form.
463
scale (1 = ‘strongly disagree’ to 7 = ‘strongly agree’) consists of 12 forward and 8 reverse scored items. Following the appropriate recoding, responses to each item were aggregated with higher scores indicating greater negative attitudes about Indigenous Australians (Pedersen et al., 2004). This scale was reported to have high internal consistency (Cronbach's alpha = 0.92). In this study, the Cronbach's alpha calculated on data collected at baseline was 0.85 and 0.88 at follow-up. The KIC scale was an investigator-developed 3-item measure, used to measure students' self-reported knowledge, interest and confidence in working with Indigenous Australians, based on the key components that have been highlighted in the literature (NSW Department of Community Services, 2009; Pedersen et al., 2006). Each item is on an 11-point Likert scale (example: How confident are you of your ability to work with Australian Indigenous peoples? 0 = ‘Not at all confident’ and 10 = ‘Completely confident’). The KIC scale scores were calculated by aggregating the total scores of this 3-item measure. In this study, the Cronbach's alpha of this 3-item scale on data collected at baseline was 0.60 and data collected at follow-up was 0.68. The rigour of the qualitative data was reviewed in accordance to its authenticity, concreteness and actualisation. Open-ended questions were used as they are considered to be an apt method for obtaining an ‘authentic’ perspective of study participants' experiences and opinions (Seale and Silverman, 1997). An element of ‘concreteness’ was incorporated by students providing reflections of their learning experiences while being immersed and engaged within the immediate context of the unit. This in turn can potentially be applied to the development and actualisation of related educational frameworks and curricula (De Witt and Ploeg, 2006). The research team members discussed emerging themes regularly until consensus of interpretations was reached. Results
Data Analysis Socio-demographic, academic-related information and responses related to the two standardised scales were entered into IBM SPSS Statistics Version 22, and descriptive statistics were calculated. As none of the continuous variables were normally distributed, the Wilcoxon Signed Rank test was used to test for differences in ATIA and KIC scale scores between baseline and follow-up. A p value of b0.05 was considered statistically significant. The qualitative open-ended responses for each question were entered into an Excel spread sheet and analysed manually and thematically by two of the research team for recurring themes. Ethical Considerations By submitting the survey responses, students accepted that they had read the study information sheet and consented to participate in the study. Students were clearly informed that their participation in the survey was both anonymous and voluntary. The conduct of the study was approved by each of the relevant university Human Research Ethics Committees. Reliability and Rigour Although only slightly more than half of the student cohort enrolled in the unit of study participated in the study, no statistical significant differences were uncovered between participants and non-participants by age, gender or country of birth. Two standardised instruments, the 18-item “Attitude Toward Indigenous Australians” (ATIA) scale and the 3-item “Knowledge, Interest and Confidence” (KIC) scale, were included in the surveys. These were administered at baseline and at the end-of-semester follow-up. Items for the ATIA scale were developed and used to measure negative attitudes related to collective guilt, empathy and racial resentment about Indigenous Australians. This 18-item scale on a 7-point Likert
The characteristics of participants are summarised in Table 1. The mean age of participants at baseline was 27.2 years (median: 25.0, SD: 8.0) and ranged from 18 to 67. Nearly two-thirds (61.4%) was born outside Australia and about a similar percentage (63.5%) spoke other than English at home. Nearly one-quarter (23.7%) was international students. Only a small percentage (1.4%) of participants were Australian Indigenous people, similarly, only a small percentage (6.4%) had experience working with Australian Indigenous people. More than half (56.8%) of the participants obtained information about Australian Indigenous people through schools. Although most of the participants reported that they socialise with people outside their own cultural group (94.2%), less than one-quarter (22.7%) socialise with Australian Indigenous peoples. Quantitative Results: Comparisons of ATIA and KIC Scores at Baseline and Follow-up Fig. 1 shows the results of the change in negative attitude scores as measured by the ATIA scale, and the change in knowledge, interest and confidence scores as measured by the KIC scale. There was a statistically significant decrease (50.6 to 49.1, p = 0.017) in scores on negative attitudes towards Australian Indigenous peoples, and there was a statistically significant increase (15.5 to 19.1, p b 0.001) in scores on knowledge, interest and confidence in working with Australian Indigenous peoples. Qualitative Findings Four major themes emerged from the analysis of the qualitative responses to the open-ended questions. These themes included: 1) understanding Indigenous history, culture and healthcare; 2) development of cultural competence; 3) enhanced respect for Indigenous Australians' culture and traditional practices; and 4) enhanced awareness
464
L. Hunt et al. / Nurse Education Today 35 (2015) 461–467
Table 1 Characteristics of participants at baseline (n = 502). Variable Age, mean (SD) median years (range: 18 to 57 years) 27.2 (8.0) 25.0 Sex, n (%) Male 84 (16.7) Female 419 (83.3) Country of birth, n (%) Australia 194 (38.6) Born outside Australia 309 (61.4) Language spoken at home, n (%) English 183 (36.5) Other than English 102 (20.3) Both English and other than English 217 (43.2) Enrolment category, n (%) Domestic 383 (76.3) International 119 (23.7) Origin: Australian Indigenous people, n (%) Yes 7 (1.4) No 495 (98.6) Experience working with Australian Indigenous peoples, n (%) Yes 32 (6.4) No 470 (93.6) Sources of information about Australian Indigenous peoples, n (%) Media 163 (32.4) School 285 (56.8) Other 55 (10.8) Socialise with people outside participants' cultural group, n (%) Yes 473 (94.2) No 29 (5.8) Socialise with Australian Indigenous peoples, n (%) Yes 114 (22.7) No 388 (77.3) Awareness of health issues of the Australian Indigenous peoples, n (%) Yes 78 (15.5) No 424 (84.5)
of the inherent health and educational disadvantages for Indigenous Australians. All participants were identified by number.
of the health issues affecting Australian Indigenous peoples. Following this unit they expressed a greater awareness of the individual, in the context of their roles and responsibilities within Indigenous communities. Some students reported that the unit had provided them with insights into Indigenous peoples' cultural beliefs and values and their perceptions of health and illness. Students appreciated learning about significant events across the lifespan for Indigenous peoples, such as birth and death, proposing this knowledge would enable them to be more responsive to their clients' needs. Responses indicated an increased awareness of the cultural aspects of health maintenance, traditional practices and health beliefs of Indigenous communities that could influence Indigenous peoples' attitudes and distrust towards Western, biomedical modalities of health care. This is illustrated by a participant in the following extract: “Helps me on how to interact with Indigenous people. Learn why they are often hesitant to approach health care service[s]” (76). “More recognition of the importance of family and community during their treatment/healing/death process, and the way in which Indigenous peoples may perceive western medical assistance” (249).
“I'll be more concerned with the words I say and questions I ask. Knowledge of cultural aspects of Indigenous people and their perception of wellbeing will allow me to provide the best care for these patients” (504). Poignantly some students realised that their preconceptions were limited by their environment and upbringing. Interestingly these comments were expressed by both international and domestic students. Engagement in the unit broadened their knowledge and perspectives of Aboriginal culture and healthcare. “I was raised in a typical Australian (white) setting in a country town that had little to no cultural diversity. I had a small amount of prior knowledge …only had contact with Aboriginal peoples in a tourist type setting…” (712).
Understanding Indigenous History, Culture and Healthcare Indigenous History Participants reported an increased knowledge and understanding of Indigenous history and the impact of past events and government policies on the health status of Indigenous Australians. Students commented that they gained a greater appreciation of the injustices of the past which increased their awareness of the health disparities and needs of Indigenous Australians: “Because I believe to be able to achieve good health outcomes for Aboriginal people, you need to know their history and culture” (490). These qualitative insights which suggest an increased knowledge base align with the quantitative results. In some cases, the learning experiences gained in the unit served as an awakening of students' understanding of the significance of history in the lives of Indigenous people. For some students this prompted a change in attitude and a desire to look for opportunities to interact and work with Indigenous Australians. This is further supported by the quantitative data which reported an increased interest among participants to work in this field of nursing.
“Though I belong to an Indigenous community overseas, having this unit prompted me to self-reflect and understand better about Indigenous communities” (215).
“I had no real understanding or appreciation of their past injustices and the hardship they face today. I have discovered passion in myself to do what I can to help the Aboriginal people as a nurse and will be looking for work in this field once I am registered” (712).
Indigenous Culture and Healthcare Participants illustrated broadened perspectives of Aboriginal people, their culture and healthcare as a result of the unit of study. Specifically, 84.5% of participants indicated prior to this unit, they had no awareness
Fig. 1. Comparison of baseline and follow-up scores: a) attitude towards Indigenous Australians; and b) knowledge, interest & confidence scores.
L. Hunt et al. / Nurse Education Today 35 (2015) 461–467
Development of Cultural Competence A key element of cultural competence entails engagement (Duke et al., 2009). Cultural competence is not solely the recognition of difference between cultures; it is the integration of culture into the provision of nursing care (Universities Australia, 2011). It is noteworthy that while 94.2% of participants socialised with people outside their own cultural group, only 22.7% socialised with Australian Indigenous peoples. Although the quantitative data showed that negative attitudes towards Indigenous Australians improved, the fact that these participants had limited contact and/or exposure with Indigenous peoples and communities may explain why the change was not greater. On a positive note, the participants identified that they had gained insights into developing their cultural competence and would apply these strategies in the provision of effective nursing care to Indigenous peoples. They recognised the importance of being cognisant of one's own cultural values as well as those of others. They explained that as a result of improved cultural competence they believed they would be more likely to provide culturally sensitive and safe nursing care. “Knowing other values helps a lot in rendering an effective nursing care because of awareness of our differences” (73).
“It will help me to be more culturally competent and safe in my nursing practice” (451). As part of developing cultural competence, participants reported improved communication skills and enhanced perceived confidence to interact with Indigenous peoples. This finding of increased confidence correlates with the quantitative results. Participants expressed improved knowledge and skills in therapeutic communication as a result of the unit. These skills included an improved perceived ability to build rapport and therapeutic relationships with Indigenous peoples and then implement appropriate strategies for care.
465
“Being a nurse, we always have to work in a multicultural environment. This unit taught how to work in such environment and respect other culture” (552).
“Because nursing is not just a profession [about] caring and helping others to have… better health but it is also a means of respecting and accepting others culture and beliefs” (830). It is enlightening that a participant has come to the realisation that the unit has prepared students to be cognisant of the impact of their behaviours on Indigenous patients, acknowledging that culturally insensitive practices can cause humiliation and embarrassment. “Future nurses will already know how to take care of the Indigenous patients in such a way that they will not be ashamed and therefore respected” (105).
Enhanced Awareness of the Inherent Health and Educational Disadvantages for Indigenous Australians The final theme that emerged revolved around an enhanced awareness of the inherent challenges for Indigenous Australians. These challenges focussed on education and the social determinants of health. Students developed their understanding of the effects of colonisation upon the health status of Indigenous peoples in the contemporary context, such as the higher mortality and morbidity rates. Students felt they were better informed about the health and educational factors that underpin the Closing the Gap policy. In addition, some participants linked this awareness to the provision of culturally competent and safe nursing care. “I found this unit good to get to know the gap for health issues and understand the history behind the choices they make” (145).
“This will make me more comfortable and knowledgeable in dealing with Indigenous patients” (84).
“I will be able to empathise with the patient and avoid misconceptions and discrimination in the giving of care” (101).
“It will make me more confident to deal with patients from Indigenous group” (290).
“Huge impact because before this unit I did not have a good understanding of all the issues involved in the actual life of the Aboriginal people today” (357).
“Understanding health problems of Indigenous Australians and where these problems come from is imperative for providing the best quality culturally competent care” (573).
“Knowing how to build rapport to build a positive relationship” (30). Discussion Enhanced Respect for Indigenous Australians' Culture and Traditional Practices Consequently some participants described how an increased understanding of the richness of Indigenous culture and traditional practices enhanced respect. Students were exposed to the positive aspects of the culture, opening their eyes to the resiliency of Indigenous peoples despite the evident adversities they continue to face. A significant attitudinal change and positive affirmation were acknowledged by a number of participants. Furthermore they reported that their learning experiences in the unit reinforced their professional requirement to respect and value cultural diversity in the provision of therapeutic care. “The unit is valuable to nursing as it gives an insight into how Indigenous people are in regards to health and how nurses should respect and treat Aboriginal Australians” (419).
This study has revealed that completing a unit of study solely dedicated to Indigenous history, culture and health, improved negative attitudes, increased nursing students' overall confidence, desire to work with and their knowledge of the issues facing Indigenous peoples. It is not surprising that education has played a major role in challenging negative attitudes, assisting in breaking down misconceptions and stereotypes and increasing nursing students' knowledge and respect for a culture that has endured significant adversities. As Goold and Usher (2006, p. 290) point out: “A lack of first-hand information provides fertile ground for simplistic or false perceptions as most non-Indigenous nurses have had no contact with, or knowledge of, the Australian Indigenous person or their history…”. This is confirmed by our study, which indicated 77.3% did not socialise with Indigenous people. Their knowledge about Indigenous history, culture and healthcare was gained from prior school learning or the media, which may perpetuate negative stereotypes.
466
L. Hunt et al. / Nurse Education Today 35 (2015) 461–467
Our findings support others in that a greater awareness and understanding of Indigenous history, Aboriginal protocols, culture and healthcare issues (including the inherent health and educational disadvantages) better prepares nursing students for the clinical environment and for deliverance of culturally-sensitive healthcare (Durey, 2010; Fredericks, 2006; Goold and Usher, 2006). While it may be difficult for some non-Indigenous students to hear about, reflect on and accept the injustices of the past (Durey, 2010), having an awareness of how oppression, racism, marginalisation and disempowerment of a cultural group and how it can have significant ramifications for quality patient care, is paramount. As others have advocated and as this unit of study has done, when educating others about Australian Indigenous peoples, nursing students need to be provided the opportunity to reflect on their own beliefs and culture (which may be influenced by ingrained beliefs and biases about other cultures) and be challenged in a safe environment (Durey, 2010). Durey (2010) insists that it is not enough to provide a ‘piecemeal’ approach to cultural education, rather prejudices and stereotypical misconceptions need to be challenged openly. In this way issues can be addressed and reconciled so that nursing students' practices embrace the importance of ‘respecting the difference’ (NSW Health, 2011). Similarly, providing sufficient depth to cultural learning experiences has implications for increasing students' confidence in their own communication skills in the clinical context. Students in this study indicated that their initial unease about communicating effectively with Indigenous clients was dispelled over the course of the unit, after increasing their knowledge of Indigenous cultural practices and health beliefs. The beneficial outcomes in this regard indicated that students may translate increased knowledge and understanding about Indigenous populations into nursing action, through greater confidence in communicating with clients appropriately for effective healthcare. As previously outlined, professional communication skills are a primary action of culturally competent nursing care (Thackrah et al., 2011). Providing the means for nursing students to be confident in engaging in safe and effective clinical interactions with their Indigenous clients in the future, as occurred in this unit, is therefore integral to improving Indigenous peoples' health status more broadly. It is timely to note, as others have done in previous literature, that such education needs to be sustained and consistent throughout nursing courses for meaningful development of cultural competence (Durey, 2010). Participant perceptions revealed that the unit had generated student interest in the field of Indigenous health, sparking in some a desire to work with Indigenous people and communities in the future. Campinha-Bacote (2008) proposed that possessing cultural desire, or personal willingness, was a crucial foundation for beginning the process of developing cultural competence. Central constructs such as caring, social justice and humility were considered essential for authentic engagement with this process. Several participants in this study reported similar personal responses to the learning experiences of this unit. Their cultural desire was characterised by burgeoning interest, passion and genuine openness to learning about oneself and others. Some participants indicated a new sense of purpose in embarking on a nursing career that incorporated culturally competent care of Indigenous peoples. The findings of this study confirmed the role of cultural desire in student engagement with becoming culturally competent. They also support the possibility of fostering attitudinal changes within the affective domain through cultural learning experiences. Mixed methods evaluations, such as this study, shed further light on the effect of cultural education on student attitudes and aspirations. However, as indicated by the findings, the completion of a single unit of study is unlikely to directly lead to cultural competence. Williamson and Harrison (2010) warn against a ‘cookbook’ approach to culturally appropriate care. Such can lead to stereotyping that is counterproductive and also impacts on the competently safe care of individuals (Alexis, 2011; Durey, 2010). Furthermore, a focus on cognitive aspects such as traditions, values and culture is insufficient as “it fails to take
into account broader, social, political and economic factors which affect health” (Williamson and Harrison, 2010, p. 765). For example, the political underpinnings of Indigenous health in New Zealand are notably different to those affecting Australia's Indigenous population. Despite these reservations, the improved communication and confidence reported by respondents in this study are commendable. The acquisition of new or revised knowledge should be interpreted positively. As a starting point, it should be built on. As previously noted, engagement is a key element (Duke et al., 2009). Personal contact with Indigenous Australians has been shown to be “a statistically significant factor of appropriate post-unit attitudes” (Ramsay and Kermode, 1997, p. 38) concerning Indigenous health. In addition to this, other considerations to enhance the culturallycompetent relevance of this unit involve the inclusion of Indigenous community members as culturally-specific educators (Nguyen and Gardiner, 2008), increased interaction with Indigenous people, especially in a clinical setting (Goold and Usher, 2006), and greater emphasis on personal reflection (Williamson and Harrison, 2010). Moreover, as providing culturally appropriate nursing care is a daily reality that affects all levels of nurses (Williamson and Harrison, 2010), a further consideration is the embedding of cultural competence and safety education in postgraduate education. The encouragement of a transformational shift to cultural safety is facilitated by culturally-informed nurse leaders (Duke et al., 2009; Goold and Coulthard, 2009). Limitations There were limitations to this study. The number of students enrolled in the unit and eligible to participate was 944. Student's participation in the baseline and follow-up surveys varied. The baseline survey recruited 502 participants this decreased to 249 participants in the follow-up survey. Due to the small participation rates the results may not be reflective of the learning of the entire cohort of students. Due to the limited participants the results may not be reflective of all students learning outcomes and attitudes towards Indigenous people and Indigenous health issues in Australia. Conclusion The findings of this study are well supported in the literature. If health care professionals are to make an impact in the area of Indigenous health and work towards “Closing the Gap”, Indigenous health issues, cultural competence and cultural safety should form an integral part of undergraduate nursing curriculum. Immersion in Indigenous related placements and Indigenous lecturers to provide real-life experiences is necessary to facilitate this. There are multiple barriers to this proposal. Financial constraints, staff resources, equitable experiences for students, student numbers, the clinical calendar, and the ability of the lecturer to attend multiple campuses are just some of the constraints. Possible ways forward include expanding the availability of Indigenous health placements and the use of the blended learning environment to enhance the students' experience and knowledge of Indigenous health issues. References Alexis, O., 2011. Health and cultural sensitivity in a diversifying society. Br. J. Healthc. Assist. 5 (6), 297–298. Australian Human Rights Commission, 2010. Social justice report: Aboriginal and Torres Strait Islander Social Justice Commissioner. Retrieved 22 May, 2014, from. https:// www.humanrights.gov.au/sites/default/files/content/social_justice/sj_report/ sjreport10/pdf/sjr2010_full.pdf. Australian Institute of Health and Welfare, 2004. Health inequalities in Australia: mortality. Retrieved 22 May, 2014, from. http://www.aihw.gov.au/publications/phe/hiam/ hiam.pdf. Australian Institute of Health and Welfare, 2012a. Australian trends in life expectancy. Retrieved 22 May, 2014, from. http://www.aihw.gov.au/australian-trends-in-lifeexpectancy/.
L. Hunt et al. / Nurse Education Today 35 (2015) 461–467 Australian Institute of Health and Welfare, 2012b. The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples. Retrieved 22 May, 2014, from. http:// aihw.gov.au/mortality-indigenous/. Campinha-Bacote, J., 2008. Cultural desire: caught or taught? Contemp. Nurse 28, 141–148. De Witt, L., Ploeg, J., 2006. Critical appraisal of rigour in interpretive phenomenological nursing research. J. Adv. Nurs. 55 (2), 215–229. Duke, J., Connor, M., McEldowney, R., 2009. Becoming a culturally competent health practitioner in the delivery of culturally safe care: a process oriented approach. J. Cult. Divers. 16 (2), 40–49. Durey, A., 2010. Reducing racism in Aboriginal health care in Australia: where does culture education fit in? Aust. N. Z. J. Public Health 34 (S1), 87–92. Fredericks, B., 2006. Which way? Educating for nursing Aboriginal and Torres Strait Islander peoples. Contemp. Nurse 23 (1), 87–99. Goold, S., Coulthard, R., 2009. CATSIN welcomes national uniformity in nursing education. Aust. Nurs. J. 16 (8), 37. Goold, S.S., Usher, K., 2006. Meeting the health needs of Indigenous people: how is nursing education meeting the challenge? Contemp. Nurse 22 (2), 288–295. Harding, S., 2004. Mortality of migrants from the Caribbean to England and Wales: effect of duration of residence. Int. J. Epidemiol. 33 (2), 382–386. Lee, C., Anderson, M., Hill, P., 2006. Cultural sensitivity education for nurses: a pilot study. J. Contin. Educ. Nurs. 37 (3), 137–141. Liaw, S., Lau, P., Pyett, P., Furler, J., Burchill, M., Rowley, K., et al., 2011. Successful chronic disease care for Aboriginal Australians requires cultural competence. Aust. N. Z. J. Public Health 35 (3), 238–248. Nash, R., Meiklejohn, B., Sacre, S., 2006. The Yapunyah project: embedding Aboriginal and Torres Strait Islander perspectives in the nursing curriculum. Contemp. Nurse 22 (2), 296–316. Nguyen, H.T., Gardiner, A., 2008. Indigenous community members as teachers of indigenous health. Aust. Fam. Physician 37 (12), 1019–1031. NSW Department of Community Services, 2009. Working with Aboriginal people and communities: a practice resource. Retrieved 4 November, 2014, from. http://www. community.nsw.gov.au/docswr/_assets/main/documents/working_with_aboriginal. pdf. NSW Health, 2011. Respecting the difference: an Aboriginal cultural training framework for NSW Health. Policy document PD2011_069. Retrieved 22 May, 2014, from. http://www0.health.nsw.gov.au/policies/pd/2011/pdf/PD2011_069.pdf. Nursing and Midwifery Board Australia, 2006. Code of professional conduct for nurses in Australia. Retrieved 3 December, 2013, from. http://www.nursingmidwiferyboard. gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx#codeofethics.
467
Nursing and Midwifery Board Australia, 2010. National competency standards for the registered nurse. Retrieved 22 May, 2014, from. http://www.nursingmidwiferyboard. gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx. Nursing and Midwifery Board of Australia, 2002. Code of ethics for nurses in Australia. Retrieved 3 December, 2013, from. http://www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements.aspx. Pedersen, A., Beven, J., Griffiths, B., 2004. Attitudes towards Indigenous Australians: the role of empathy and guilt. J. Community Appl. Soc. Psychol. 14, 233–249. Pedersen, A., Dudgeon, P., Watt, S., Griffiths, B., 2006. Attitudes toward indigenous Australians: the issue of “special treatment”. Aust. Psychol. 41 (2), 85–94. Ramsay, L., Kermode, S., 1997. Nurses facilitating reconciliation through education. Aust. J. Adv. Nurs. 15 (1), 32–39. Reibel, T., Walker, R., 2010. Antenatal services for Aboriginal women: the relevance of cultural competence. Qual. Prim. Care 18, 65–74. Salamonson, Y., Andrew, S., Clauson, J., Jacobs, S., Cleary, M., Jackson, D., 2011. Linguistic diversity as sociodemographic predictor of nursing program progression and completion. Contemp. Nurse 38 (1–2), 84–93. Seale, C., Silverman, D., 1997. Ensuring rigour in qualitative research. Eur. J. Pub. Health 7 (4), 379–384. Stuart, L., Nielsen, A., 2011. Two Aboriginal registered nurses show us why black nurses caring for black patients is good medicine. Contemp. Nurse 37 (1), 96–101. Thackrah, R., Scott, K., Winch, J., 2011. Indigenous Australian Health and Cultures: An Introduction for Health Professionals. Frenches Forest, Pearson Australia. Turale, S., Miller, M., 2006. Improving the health of Indigenous Australians: reforms in nursing education. An opinion piece of international interest. Int. Nurs. Rev. 53 (3), 171–177. Universities Australia, 2011. National Best Practice Framework for Indigenous Cultural Competency in Australian Universities. Department of Education, Employment and Workplace Relations, Canberra. Webster, S., Lopez, V., Allnut, J., Clague, L., Jones, D., Bennett, P., 2010. Undergraduate nursing students' experiences in a rural clinical placement. Aust. J. Rural Health 18, 194–198. Williamson, M., Harrison, L., 2010. Providing culturally appropriate care: a literature review. Int. J. Nurs. Stud. 47 (6), 761–769. Wingate, M., Alexander, G., 2006. The healthy migrant theory: variations in pregnancy outcomes among US born migrants. Soc. Sci. Med. 62, 491–498.
