Many Indigenous people in rural and remote areas need to travel vast distances to hospitals for surgery, often with life-threatening conditions. Language issues, poor inter-agency co-ordination, cultural misunderstandings, emotional and physical stress, travel and financial problems can all make this a difficult, dangerous and inefficient process for the patient and the health system.
These concerns led Monica Lawrence, a nurse in the cardio-thoracic ward at Flinders Medical Centre in Adelaide, to initiate a research project to test whether better system co-ordination and cultural support could lead to better patient outcomes and hospital efficiencies, and reduced waiting time and costs. Monica started her own quality improvement study in the ward, and this led her into undertaking a Master of Nursing by Research. Other project team members were Zell Dodd, Shane Mohor, Sandra Dunn, Charlotte de Crespigny, Charmaine Power and Laney MacKean.
Research aims and activities:
The research aimed to find out ways to improve clinical practice and health system performance when working with Indigenous people who travel from remote settings to have cardiac surgery and treatment. Within the hospital’s continuous quality improvement (CQI) framework, action research and community development approaches were used to collect and analyse data and to identify areas that needed to change. Research activities included:
- identifying the barriers and enablers in the patient pathway
- conducting case studies which focused on the experiences and perspectives of four patients and explored their understanding about their medical and surgical treatment. Health care professionals were also interviewed to get a picture of the interface between primary and tertiary based care for each patient.
- trialing a Remote Area Nurse Liaison Service in the first half of 2007. The service aimed for continuity of care through a clinical/cultural approach and involved liaison with the agencies that provide patient preparation, transport and post-operative care
Towards the end of the Masters research, I collaborated with Barbara Beacham, a program manager at the CRCAH, who helped me take a strategic point of view. We decided the best way to implement the findings was through a role that could trial them. We proposed the Remote Area Cardiac Liaison Nurse position. This meant presenting a business plan, so we had to think strategically and say ‘Which audience wants to hear what? … I had to transcribe patients’ experiences into bed numbers and stays, costs and savings for managers.
The trial found that improved cultural competency in a clinical setting led to better clinical/cultural liaison, more cultural respect for remote area Indigenous patients, better informed patients, improved patient care and safety, lower travel costs, less disruption in the hospital system and more efficiency in the hospital. For example:
- formalising a process for pre-operative screening in the community meant that undetected health problems were picked up before patients travelled all the way to Adelaide for surgery; before this, patients regularly had to be sent home without surgery.
- an informed consent process conducted in the community in patients’ own languages by Aboriginal liaison health officers informed patients and family members properly and prepared them psychologically.
- the trial Liaison Service resulted in a dramatic decline in cancelled surgery (due to ‘no shows’ or poor patient preparation) from 50% of remote area patients to 0%. Flow-on effects were better efficiency in the hospital and cost savings on patient travel bills.
- arranging a process for post-operative follow up in the community led to better patient recovery.
Using research for change – the outcomes:
As a result of the research, Flinders Medical Centre now has a full-time remote liaison nurse position, and CQI processes reflect these clinical/cultural competencies. There is a cardiac rehabilitation program for Indigenous patients.
The research has helped develop ‘step-down’ programs for Indigenous patients after discharge. Country Health SA has rolled out the model in the ‘Clinical Networks’ program, and other health care programs are looking at using the learnings.
The evidence adds to a push to improve Patient Assistance Transfer Schemes across Australia. The research has influenced national health care policy, through a submission to the 2007 Senate Inquiry and inclusion of three standards for acute care services to Indigenous people by the Australian Council on Healthcare Standards.
I also had to think politically…. The CRCAH helped to write a policy brief and summary report. Good media promotion and the launch of the summary report at a primary health care round table in Canberra were the main drivers. They sparked a high level of interest on the national stage and SA Health regions took notice.
Factors that contributed to knowledge exchange included:
- research that was based on needs identified by a practitioner
- clearly stated, practical key messages
- targeting people or groups who had political clout to influence change and talking in their language
- timing the research to influence change
- persistence by the researcher
- support by others with links and expertise to help get messages across.
Many times… I thought ‘this is too hard, I can’t do it’. Here I was, a clinical nurse stepping outside my professional domain and trying to change broader practice in a hospital setting. I had to keep knocking on doors [and to]… wear the hat of a bureaucrat and talk in terms of dollars and cents, and quality and safety. [When it got] too hard… I’d put my nursing hat back on and reflect on why I undertook this research work in the first place. I still keep thinking about the first woman from a remote area that I ever looked after. She was the reason I did this research.
- Lawrence, M. with Dodd, Z., Mohor, S., Dunn, S., de Crespigny, C., Power, C. & MacKean, L. 2009, Improving the Patient Journey: Achieving Positive Outcomes for Remote Aboriginal Cardiac Patients, Cooperative Research Centre for Aboriginal Health, Darwin.
- CRCAH Project Page: Improving the patient journey - enhancing accessibility, quality and safety of hospital-based care for Indigenous patients from remote area
From Researching Indigenous Health: A Practical Guide for Researchers, Alison Laycock with Diane Walker, Nea Harrison & Jenny Brands 2011, The Lowitja Institute, Melbourne, chapter 5, pp. 128–9.