Policy – Recall and reminder system of a General Practice

A recall and reminder system is an organisational and a national policy as well as a common law duty for general practitioners (GP) developed by the Royal Australian Collage of General Practitioners (RACGP), as part of the standards used to accredite General practices (GP). A GP however can choose not to become accreditated and therefore does not have to implement such a policy,

What is known as standards were first developed as a way for Australian GP’s to have an effective and efficient, safe way of practicing.  “The RACGP is responsible for maintainstandards for quality clinical practice, education and training, and research in Australian General Practice”  (www.racgp.org.au).

The RACGP has been responsible for developing thestandards for accreditation of Australian GP’s (AGPAL).  A GP can choose to become accredited.  This means they choose to meet the required standards to ensure a safe high quality health care and continuous improvement of those health care services (AGPAL).

The recall and reminder system is set in place to allow the GP to follow up patients test results and other clinical correspondence and any screening tests or tests recommended in the future such as a 3 monthly blood tests for a diabetic patient.  In the past there has been legal cases resulting in the GP being found guilty, one example is ---

The policy is designed to provide “ continuity of care an increase in patient involvement in their health, the ability to increase practice income, better management of chronic conditions therefore leading to reduced acute care and greater preventive care better quality of life for patients” (RFDS).

The policy at this GP follows the RACGP guidelines this practice has also met AGPAL guidelines The recall and reminder policy was implemented in 2007 when the practice was first opened.  The policy was first developed by the RACGP in the early 1990’s (www.racgp.org.au/standards/hx 13/7/2011

For the recall and reminder system the first step is to identify patients that need recalling The recall and reminder system is set in place to allow the GP to follow up patients test results and other clinical correspondence and any screening tests or tests recommended in the future such as a 3 monthly blood tests for a diabetic patient. 

The policy is designed to provide “ continuity of care an increase in patient involvement in their health, the ability to increase practice income, better management of chronic conditions therefore leading to reduced acute care and greater preventive care better quality of life for patients” (RFDS).

The policy at this GP follows the RACGP guidelines this practice has also met AGPAL guidelines

The recall system at this practice is a follow- up system where patients are contacted in order to be able to receive the results of tests and follow up treatments

For the recall and reminder system the first step is to identify patients that need recalling, registering them on the system, tracking outgoing diagnostic tests requests and referrals, ensuring results and referrals arrive back at the practice, recall the patient to receive their results .

The reminder system is a process for providing patients with preventative care, this includes reminders for immunizations, pap smears and care plans

For both recall and reminder systems the practice policy requires a minimum attempt to contact the patient tree times either by phone or mail, the third attempt must be by registered letter by the practice nurse.  If no contact has been made the practice nurse must notify the GP.  There is usually one contact a month, once the three contacts have been made and the GP is aware the recall can be removed.

The aims and objectives of this policy are to ensure that patients receive optimal care and that they are followed up.

At this practice it is the role of the practice nurse to ensure this policy is carried out each month the computer generates a list of patients who are due to be recalled and the reason they are being recalled and the practice nurse is to then go through the list and contact each person, and document in their notes

In order to review and analysis this policy I have reviewed the policy itself, the RACGP, AGPAL and the GP view towards policy making

I chose this policy because it is a big part of my job, it is something that I review almost daily and Ispend a good proportion of time contacting people, there are about 150 to 170 people on the recall list each month, most of those have two and three contacts and a lot of people are moved of the recall list, often they have left town or choose to see another doctor elsewhere without informing us and occasionally choose to ignore the recall and don’t come in to see the doctor.  It becomes very frustrating seeing the same names over and over. On the other hand for the patients with chronic illness who do attend their appointments when they are recalled it is a very rewarding experienceespecially as it improves their health or allows the Doctor to provide appropriate treatment

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The effects of the social determinants of health on Remote area nurses in Australia

Part A: Framing a research question

When searching the literature on Remote Area Nurses (RAN’s) there has been much research on the effects they have on Indigenous health, nurse burnout, stress, violence in the workplace and workplace retention, there is much written and researched about the effects of adverse social determinants on Indigenous health including remoteness, poor living conditions, lack of fresh quality food, poor housing and sanitary conditions, but almost nothing on the health of the individual RAN who faces similar living and working conditions as well as the social determinants of health as the population they are caring for.  “Social determinants of health are the social and environmental conditions in which people live and work” (World Health Organisation, 2007, p1).  Some of the major social determinants of health include (SACOSS, 2008),

•

Healthy living conditions such as access to food, water, sanitation and accommodation

•

Education, literacy and health literacy

•

Stress

•

Early life

•

Social exclusion

•

Employment and unemployment

•

Age, sex and hereditary factors

•

Culture, racism and discrimination

•

Access to information and appropriate health care

•

Social supports and access to transport

There appears to be a gap in the literature in addressing the health of RAN’s and how living and working in remote communities affects them and their health.  There is little information on whether or not a RAN working long term in a remote community may face the same health problems as those they look after.  Thinking about this I began to wonder if the social determinants of health that so adversely affect the health of Aboriginal populations living on remote communities would also impact on others that live there such as nurses.

I have included the PICO worksheet and search strategy below in order to outline and define my research question.

1.   Define your question using PICO by identifying: Problem, Intervention, Comparison Group and Outcomes.

Your question should be used to help establish your search strategy.

Patient/Problem_______Remote Area Nurses in Australia_________________________

Intervention__________Social determinants of health_________________________

Comparison_______Health status of Remote Area Nurses____________________________

Outcome__________The effects social determinants have on Remote Area Nurses health________________________

Write out your Question: ____What are the effects of the social determinants of health on Remote Area Nurses in Australia?_________________________________________________

2.   Type of question/problem:

Circle one: Therapy/Prevention Diagnosis Etiology Prognosis

Human Interest

3.   Type of study (Publication Type) to include in the search: Check all that apply:

Meta-Analysis  ❏     

Systematic Review  ❏

     Randomized Controlled Trial  ❏     

Cohort Study  ❏     Case Control Study  ❏     Case series or Case Report  ❏     

Editorials, Letters, Opinions  ❏     Animal Research  ❏     In Vitro/Lab Research  ❏     

Qualitative  ❏

4.   List main topics and alternate terms from your PICO question that can be used for your search

List your inclusion criteria – gender, age, year of publication, language

In this research question Remote Area Nurses (RAN’s) will be surveyed – a RAN is classified as someone who works in remote Australia For the purpose of this research. The Rural and Remote and Metropolitan Areas (RRMA) classification considers a remote zone to have a population of 5000 or less.  

Geographical location - There are also geographical criteria to help define remote areas (Strong, Trickett, Titulaer & Bhatia, 1998).

Gender and age are irrelevant, this study will focus on any nurses who live and work in remote Australia

Language – English

Year of publication – 1970 -2011, it is important to look back and see if there have been any changes to Remote area nursing and the working and living conditions and role that the nurses perform.

Search terms include – RAN, social determinants, health, ill health, remote, Australia, aboriginal communities

List irrelevant terms that you may want to exclude in your search

Hospital, wards,

5.   List where you plan to search

Data bases including Medline, CINAHL, Cochrane, PubMed, Nursing Consult and Health Collection

Part B: Literature review

I have selected two research articles that touch on some issues faced by RAN’s but do not directly address any potential health issues that may be faced by individual RAN’s.  There is a gap in the research that needs to be addressed.

Article one:

What stresses remote area nurses? Current Knowledge and future action

Author:

Lenthal, Wakerman, Opie, Dollard, Dunn, Knight, MacLeod & Watson (2009).

Article two

Concerns, satisfaction and retention of Canadian Community health nurses

Author:

Armstong-Stassen & Cameron (2005).

Overlapping concepts in each of these articles, highlight some of the issues faced by RAN’s

See appendix one for a full list of concepts from each article and those that overlap.  Three concepts in particular will be explored in futher detail to show the reader how potential social determinants of health can indeed advesrsly impact on the health of the RAN.

Concept	Author / year/ primary (P) or secondary(S) citations
Impact of stress	Lanthall, et al, 2009 (S); Armstrong-Stassen et al, 2005(S).
Lack of support from management and social support	Lanthall, et al, 2009 (P); Armstrong-Stassen et al, 2005 (S).
Lack of adequate resources	Lanthall, et al, 2009 (P); Armstrong-Stassen et al, 2005(P).

The impact of stress on RAN’s can be related to demanding workloads, professional and social isolation, skill levels required, high mortality and morbidity rates and the considerable effort required to meet the job demands (Lenthall, et al, 2009).  Other areas that can contribute towards stress in the workplace include lack of support, unclear roles, increase workloads and unreasonable expectations (Armstrong-Strassen & Cameron, 2005). The emotional and psychological distress caused by the job can also impact on the remote area and community nurse and contribute to increase stress levels and lead to potential burnout (Armsrong-Strassen, & Cameron, 2005).  The Australian Medical Association (AMA), describes long term stress as damaging to health, stress can impact negatively on mentalhealth as well as contribute negatively to the body’s stress response causing harm to the cardiovascular and immune systems (AMA, 2007).  Long term stress can cause infections, obesity, diabetes, hypertension, stroke and depression (AMA, 2007).  The AMA (2007, p3) also lists “continuing anxiety, insecurity, social isolation and lack of control over work and home life” as stressors, all of which a RAN faces in her/his daily life.

Lack of support from management and lack of social support can impact negatively on aRAN’s health.  Lenthall et al (2009) state that -

“Working in isolation is the most pervasive feature of remote area life.  Isolation extends beyond geography to encompass social and professional life.  In particular, the social support provided by family and friends is less accessible.  This can increase the sense of personal and professional isolation”

Not having colleagues around to discuss cases, lack of communication and lack of support from management can impact on the sense of professional isolation (Armstrong-Strassen, et al, 2005).  Social exclusion is identified as the lack of connection to the community in which a person lives, racism, discrimination, stigmatisation and unemployment can also contribute (AMA, 2007).  A RAN may have different cultural and religious background to those they look after.  living in a remotely for work may mean living many hundreds of kilometres away from extended family and long term friends.  A lack of connectedness to family, friends and community is known as social interaction these can have negative impacts on physical and mental health (SASSOC).  Social support and social relations have a positive impact onhealth and can even provide a buffer agent against health issues (AMA, 2007; SASSOC).

Much has been written regarding access Indigenous people have to health care in remote Australia.  Lenthall et al, 2009; Armstrong-Strassen, Cameron , 2005,  point out there is a lack of adequate funding, resources and training provided to RAN’s and community healthservices making it difficult for the nurses to do their jobs.  The nurses who live on these communities have access to the same standard of health care as their clients, due to physical isolation such as floods and no staff to relieve them.  Lack of funding and resources affect everyone that lives remotely, if the truck can’t get into the community with fruit and vegetables then everyone living in the community goes without including RAN’s.

Part C: Construction of an appropriate research methodology and method

Research design:

In order to answer the research question – What are the effects of the social determinants of health on Remote Area Nurses in Australia?

A qualititative method is best.  Qualititative research is interested in human experience, values, consciousness and subjectivity (Taylor, et al, 2006).  The methodology best suited to this question is Grounded Theory.  Grounded Theory is ideal for topics/questions where not much is known and the researcher can start from the ‘ground’ up (Taylor et al, 2006).  Grounded theory allows the researcher to use various modes of data collection such as interviews, the data is then compared and hypotheses are generated, problems and solutions can be identified using this theory (Taylor et al, 2006).  

Participants:

RAN’s are defined by the RRMC and geographical criteria as above.  Age and gender are irrelevant in this study.  Each community falling in the above category will be contacted by phone initially and then a mail out will be sent to the community for nurses to participate in.  As the participants won’t be identified by approaching CRANA or the Nurses RegistrationBoard this will help with confidentiality but may limit the participation of the recipients.

Research Setting

Due to the distances in Australia and the difficulty in accessing remote communities the researchers will choose one or two communities to visit to interview and observe the RAN and even practice nursing to experience the adversity’s first hand.  The collection and dataanalyisi will be done at the researchers home town.

Data Collection

Data collection will be largely done by questionnaire mailed out to the participants with one or two observation placements to allow the researcher to talk and observe RAN’s and experience firsthand the adversities faced 

Data Analysis

Qualitative data needs to be reviewed and maid ideas and themes need to be grouped, fromthese central ideas and theories will begin to emerge.

Ethical considerations

Ethical research is concerned with moral questions and behaviours during research, it has been put in place to ensure no harm comes to the participants (Taylor et al, 2006).

When pursing research it is important to obtain approval from a Human Research EthicsCommittee (Taylor et al, 2006).  The Australian Nursing Federation and the National Health and Medical Research Council (NHMRC) have developed guidelines or codes for the standards for ethics and nursing research (Taylor et al, 2006).  The nursing researcher should be familiar with these standards and codes and follow them to the letter to ensure ethical research has been carried out (Taylor et al, 2006).  Below is a brief outline of issues to consider when undertaking ethical research

Specify any psychological and other risks to the participants

•

While doing qualitative research that involves interviews and questionnaires that request details of personal life’s and the revelation on confidential information the researcher can cause the participant psychological and emotional harm, the questions/interviews may bring up distressing memories, force the participant to face thoughts and memories or draw conclusions that they may not wish to face or may not be ready to face (Taylor, et al, 2006).  

What steps will be taken to ensure protection of the participant’s physical, social and psychological welfare? Will the participants be assured that they may withdrawal from the study at any time without fear of the consequences?

•

Full disclosure of the research will be provided, informed consent and the assurance that the participant will remain confidential and have the right to withdrawal at any time with no consequences.  This is essential to ethical research and is a requirement when providing information and obtaining consent (Taylor et al, 2006). The RAN’s will be provided with information and contact details of counselling services, (Bush Help Line) and organisations such as CARANA.

Will the aims of the study be communicated effectively to the participants? How will this be done?

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Full disclosure of information.  

•

Identity of the researcher;

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Purpose of the study

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Nature of the study;  

•

The right to refuse to participate, or withdrawal at anytime

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The responsibilities of the researcher

•

Possible benefits of the study, risk or side effects

•

Alternative treatments

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Measures taken to protect privacy

•

Ensure anonymity and confidentiality. (Taylor et al, 2006, p101).

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The researcher will be providing the RAN’s with a plain language statement which is used to provide information such as listed above to the participants in a language they can understand.  

What steps will be taken to ensure informed consent of the participants/guardians?

•

Each RAN will also receive an informed consent form.  The consent form will be developed outlining this particular research, how it will be conducted and the requirements of the participants.  The RAN’s after reading all the information may simply choose not to participate.  If they send their questionnaires back, as they are not identified on their questionnaires it will be difficult to remove their responses once submitted.  This may limit participation .

Describes the measures which will be taken to ensure the confidentiality of the participants. If confidentiality is not ensured justify?

•

Each RAN will not be asked to give out personal details that would identify them, although the questionnaire will ask for age, gender, work and education experiences to help see if there is a comparison between these factors and any ill health described.Returned consent forms will be separated from the questionnaires and storedseparately.

Explain how you intend to store and protect the confidentiality of the data

•

Upon receiving the returned questionaries and the notes of the interviews and observations will be locked in a filing cabinet in the researcher’s offices

Check text book for further storage advise

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Appendix one – Key concepts of each article

Article one:

What stresses remote area nurses? Current Knowledge and future action

Author

Key concepts

1.

Remote area nursing is characterised by geographical, social and professional isolation

2.

RAN’s provide many aspects of primary health care

3.

The context of RAN work is extremely demanding

4.

RAN’s experience increased levels of occupational stress

5.

High turn over rates

6.

Impact of stress on RAN’s

7.

Lack of funding and resources mean lack of accessible and acceptable standards of health care

8.

Job demands become stressors when RAN’s need to expand considerable effort in order to meet them

9.

Decrease social support

10.

Physical and emotional exhaustion caused by long working houirs and continous on-call, high level of skills needed to perform tasks requiured

11.

Cultural differences

12.

Poor management practices, lack of support provided by management who are often hundreds of kilometeres away

13.

Little or no orientation to a new work place

14.

Work place violence

15.

Established support services and high quality education services now being made readily available

16.

Limited literature on the effect of stressors on RAN’s

Article two

Concerns, satisfaction and retention of Canadian Community health nurses

Author

Key concepts

1.

Little research on community health nurses

2.

Increase number of clients

3.

Large case loads

4.

Complexity of care required

5.

Lack of adequate resources

6.

Physical danger/assault, unsafe working environment

7.

Psychological distress, emotional effects of the job

8.

Inadequate staffing

9.

Poor facilities

10.

Lack of equipment

11.

Working with vunneralbe families with many problems

12.

Inadequate resources to do the job

13.

Lack of support from management

14.

Lack of information and communication between management, staff and clients

15.

Unclear roles

16.

Lack of access to technology

17.

Increase workload demands

18.

Working conditions – time required to travel, car costs, isolation from agency base

19.

Adequate training needs provided

Many of these key concepts overlap

Articlae one	Article two
The context of RAN work is extremely demanding	Complexity of care required
RAN’s experience high levels of occupational stress	Psychological distress – emotional effects of the job
Impact of stress on the RAN	Increase work load demands
Lack of funding and resources means lack of accessible and acceptable standards of health care Articlae one Article two The context of RAN work is extremely demanding Complexity of care required RAN’s experience high levels of occupational stress Psychological distress – emotional effects of the job Impact of stress on the RAN Increase work load demands Lack of funding and resources means lack of accessible and acceptable standards of health care • Lack of adequate resources • Poor facilities • Lack of equipment • Inadequate resources available to do the job Decrease social support Lack of information and communication between, nurses, management and clients Physical and emotional exhaustion-long working hours, constant oncall, high complexity of cases and workload, high levelofskills needed to perform tasks requiured Large case loads Poor management practices Lack of support provided by management who are often hundreds of kilometeres away Lack of support from management Violence in the work place Physical danger/assault and unsafe working environments

Cultural safety

Aboriginals have the worst health in Australia, they suffer a higher rate of illness, have a life expectancy well below other Australians,have a greater rate of poverty, unemployment, lower levels of education, social isolation, compounded by remote living where they have access to limited health facilities and the local store supplies limited good foods (Reid & Lupton in Reid and Trompf, 1991. Commonwealth of Australia, 1998).  It wasn’t always like this, prior to European arrival  Aboriginals had good health and lived a hunter a gather lifestyle which ensured frequent exercise, they lived on a wide range of naturally occurring plants and animals allowing a well-balanced diet of protein, high in fibre and low in salt sugar and fat (Burden, 1994).  They lived in small kin based groups (Burden, 1994).

One morning a 17 year old male (Mr. X), presented to the emergency department, wrapped in a blanket and shivering cold, an older Aboriginal male was with him.  It was quickly determined that something had gone wrong with his initiation ceremony.  Mr. X was dirty, cold and covered in blood, he gave consent to be assessed, there was some concern by the older Aboriginal male as it was going against tradition for Mr. X to be seen by females during ceremony time.  It was explained that that there were no male nurses or doctors present at this time, Mr. X was aware of the risks to the ceremony but consented to be treated by female staff.  Upon examination it was found that the cut made to his penis had passed through a tiny artery and the bleeding was uncontrolled, the patient had been like this for several hours prior to presentation to the Emergency Department, he was also in considerable pain.  The patient was warmed up, cleaned up and a pressure dressing of sorts was applied to his penis, he was given fluids and kept comfortable, his contact with the hospital staff was kept to one nurse and one Doctor out of respect to the ceremony, the curtains were drawn at all times.  The patient’s parents were contacted but due to the ceremony Mr. X’s mother was not allowed to be informed of what had happened, this was extremely difficult to deal with for staff as she was quite distressed, however the patient was of the age of consent and out of respect to the ceremony confidentiality was not breeched.  Mr. X was happy for any treatment, he told staff he did not want to go back to the initiation ceremony and finish.  He was flown to the regional hospital via RFDS for emergency surgery.  When Mr. X returned he was admitted to hospital, a vague complaint of complications and back injury were told to the family by the patient but he was admitted at his request to avoid going back and continuing the ceremony, he was extremely upset and stressed by the thought of having to complete the ceremony, he may never have full use of his penis again, he stayed in hospital until after ceremony time, with the knowledge that during the next years ceremony time he would make sure he was far away.

Health and illness is experienced differently by Aboriginal men than non Aboriginal men.  The way they approach and use healthservices are very different, this is usually due to cultural reasons (Williams &Kakaious, 009).  In Aboriginal culture women’s and men’s business are kept separate and discrete, if breached punishment can result.  A great shame can be experienced by aninitiated Aboriginal man if treated by a female (Mobbs chapter 7 inReid and Trompf).  Most ceremonies practiced in Aboriginal Communities cannot be discussed fully due to their sensitive and scared nature (www.indigenousaustralia.info/culture.html).  Initiation ceremonies are preformed to introduce adolescent boys and girls as adult members of the community, by being initiated the adolescents are taught and prepared for their f\roles with\thin the community as an adult, these ceremonies can take place over years (www.indigenousaustralia.info/culture.html).  Non indigenouspeople cannot attend these ceremonies(www.indigenousaustralia.info/culture.html).  The ceremonies can include having a permanent symbol on their bodies, initiated members may have a tooth removed, their ears or noses pierced or flesh cut with particular sacred markings (www.indigenousaustralia.info/culture/inititation-ceromonies.html)

In Aboriginal culture a male going through initiation is not allowed to be seen by a female, if illness or injury occur the person often presents wrapped entirely in blankets and his contact with female staff is limited as much as possible.  Initiation ceremonies are important spirituality.  As it is taboo to be seen by females this can cause damage.  In the case of Mr. X just by presenting to the hospital and being seen by females was taboo and harmful to the initiation ceremony, only Aboriginal people know exactly the harm this causes, however urgent medical attention was required, the patient wanted treatment and consented to it, the hospital staff did what they could to maintain confidentiality and respect the ceremony as much as possible.

Cultural safety is a relevantly new concept, the idea is for nurses to provide quality care for people from different ethnicities than the mainstream, nurses must provide that care within the cultural values and norms of that patient (www.wikipedia.com). Unsafe culture practices is any action that diminishes, demeans or disempowers the cultural identity and wellbeing of an individual(The Royal Australasian college of Physicians, 2004).  Cultural safety gives Aboriginal people the power to comment on the care provided, it allows Aboriginal people to be involved in changes in health services (The Royal Australasian college of Physicians, 2004).

There are no actual guidelines available for staff on initiation and treatment of a male during this time.. Long term staff attend cultural awareness programs that cover the basics of indigenous culture such as kinship, taboo relationships, communication and lifestyle (reference).  There are also interpreter services available, and the hospital employs a liaison offer, who often helps the patients with any forms that have to be filed out, language, and getting to and from appointments.

The Northern Territory government has recently developed a policy for Aboriginal Cultural Security, the policy states that by providing culturally secure services all Territotrians can have access to safe and effective services (Aboriginal Cultural Security, 2009).  The policy requires health services to identify the elements of Aboriginal culture that affect the delivery of health and community services in the Northern Territory, to review service delivery practices to ensure they do not unnecessarily offend Aboriginal peoples culture and values, change service delivery practices where necessary and to monitor service activity to ensure that the services continue to meet culturally safe standards(Aboriginal cultural Security, 2009).  It is a strategy to improve services to Aboriginal people by making sure the way health services are delivered takes important cultural matters that may have a bearing on health and community outcomes into account (Aboriginal Cultural Security, 2009).  The Department of health and community services will work closely with Aboriginal communities, some changes to services provided; the number of Aboriginal people employed and the way quality is assessed in the workplace (Aboriginal Cultural Security, 2009).This policy of cultural security is a commitment to further strengthen Aboriginal people’s access to health and community services.  Ideally this policy would see health services develop partnerships with aboriginal peoples to better improve the way they view and access health services.

Australian Nursing and Midwifery council code of professional conduct for nurses in Australia (2008) “sets the minimum standards for practice a professional person is expected to up hold both within and outside of professional domains in order to ensure the ‘good standing’ of the nursing profession” (pg 1).  Standard 4 of the code states “Nurses respect the dignity, culture, ethnicity, values and beliefs of people receiving care and treatment and of their colleagues” (pg 1).  Nurses should uphold the standards of culturally informed and competent care, ensure the safety and quality of care is not compromised because of harmful prejudicial attitudes about race, culture, ethnicity, gender, sexuality, age, religion, spiritually, political, social or health status (Code of Conduct, 2008, pg4)

The Code of Ethics for nurses in Australia outlines the nursing professions commitment to respect, promote, protect and uphold the fundamental rights of people who are both recipients and providers of nursing and health care. Value statement 3 of the code states “Nurses value the diversity of people” (pg6).

.

Health professionals can only provide quality health services to the extent that they understand the attitudes, customs and beliefs of Aborigines (Germanos-Koutsouadis, 1990).  Building cultural security reduces conflict, improves quality and outcomes, enhances efficiency and improves customer satisfaction (Aboriginal Cultural Security, 2009).  In order to achieve good cultural safety, further in-depth cultural awareness programs should be offered, to all staff including the staff on short term contracts.  Employment of male and female Aboriginal health workers to assist with language barriers, communication problems, follow up and to aid in good , care and instructing in regards to men’s and women’s business.  High staff turnover, lack of specific knowledge about the cultural variables of different groups can also cause problems.  Changes to health services include improving knowledge base of all staff employed, changing public health , clinical and administrative practices to incorporate critical cultural standards, monitoring progress and continuing services provided, ensuring the Aboriginal community is involved in developing and monitoring polices implemented by health services.

The Northern Territories Department of health and familiescorporate plan 2009-2012 recognises that developing and delivering a system of services that is underpinned by culturalsecurity, safety and quality is essential for the effective delivery of health services.  The department of health and families Aboriginal and Torres Strait Islander Strategic workforce plan 2008-2011 recognises strengthen the Aboriginal and Torres Strait Islander workforce is a priority to help and improve the economic and social health and well being of  Aboriginal and Torres Strait Islander people, building a sustainable Aboriginal and Torres Strait Islander workforce, strengthening a capable Aboriginal and Torres Strait Islander workforce, attraction and retention of Aboriginal and Torres Strait Islander talent and optimizing the Aboriginal and Torres Strait Islander workforce.

Reference List

Aboriginal Initiation Ceremonies 2009,www.indigenousasutralia.info/culture/initiation-ceremonies.html    

Accessed 22/08/09

Introduction aboriginal Culture, 2009www.indigenousaustralia.info/culture.html  accessed 22/08/09

Aboriginal Cultural Security an outline of the policy and its implementation (2009).  Department of health and Community Services Northern Territory Government.  

accessed 20/08/09" www.nt.gov.au/health  

accessed 20/08/09.

Burden, J. 1994, ‘Health: A holistic approach’, Aboriginal Australia, eds C. Bourke, E Bourke & B. Edwards, University of Queensland Press, Brisbane, pp 162-7 & 159-62.

www.wikipedia.com accessed 19/08/09

Germanos-Koutgoundis, V, 1990 “Fair go” access and equity issues for Australians with disabilities who are from non-english speaking backgrounds (NESB), Aboriginal, Torres Strait Islanders, women and from remote areas, Australian Disability review, vol 3, pp3-10.

Code of Ethics for Nurses in Australia

Code of Professional Conduct for Nurses in Australia

Mobbs, R 1991. In sickness and health: the sociocultural context of Aboriginal well-being, illness and healing p292-325 in Reid and Trompf, the health of Aboriginal Australia

Reid & Lupton

Australian Introduction to cultural Competency (2004) An Introduction to cultural competencywww.australianindigenousdoctorsassociation.com.au accessed 04/08/09.