A culture of care in the Red Centre
The importance of cultural awareness training has very practical implications for Sara Kirwan. As the only pain physiotherapist servicing Alice Springs Hospital and the many surrounding remote Aboriginal communities in the Northern Territory, Sara draws on her cultural awareness training daily in both her work and personal life.
Sara Kirwan, APAM, chuckles a little at the strange happenstance that has led her to no longer consider Alice Springs a ‘remote town’.
After all, it was less than 23 years ago Sara was living in the bustling metropolis of London, a city she had partly grown up in after her family divided their time between the United Kingdom and Hong Kong.
London was also where Sara’s career took off initially in the NHS and then working for the Metropolitan Police as a physiotherapist while simultaneously completing her diploma in exercise and health science at the University of Surrey.
So, having lived in busy London, a city with a population of 8.9 million people, how then could Sara not find Alice Springs, with its population of just over 25,000 people, remote?
The answer lies in Sara’s journey to Australia to take up a year-long role as the senior physiotherapist at the Carnarvon Regional Hospital in Western Australia.
It was at Carnarvon, which has a population of just over 4420 people, that Sara was introduced to working with local Yamatji Aborignial patients.
‘I was with the Gascoyne Health Service as the senior physio at Carnarvon Hospital,’ Sara says.
‘There were only two physios in the department and we covered a large regional area—every fortnight I would fly to Exmouth and do a two-day clinic there, and on the interim fortnights I would fly to Denham, which is in Shark Bay, and do a half day clinic there.
‘All I knew about Carnarvon before I arrived was that it was a small town. I knew it grew mangoes and bananas, and that it was on the coast.
'I didn’t quite appreciate the distances from the major metropolitan area or the fewer resources that might be available to me, and that was a huge culture shock.
In Denham, for example, I very much had to make do—I was working out of the back of an ambulance shed.’
Sara admits she knew little about Aboriginal culture, history and traditions before coming to Australia on her working holiday, which has now turned into a permanent stay.
Most of what Sara did learn in her first role here was learnt on the job.
‘Back then, there was certainly no orientation like I’ve had in my current role. You literally just had to feel your way through,’ Sara says.
‘Growing up in Hong Kong, in London, in the different cultures, I got used to adapting and respecting and being non-judgmental about people’s culture and beliefs. I think that really did help me to settle in Australia and to form relationships and build rapport with people.’
Fast-forward 23 years and the Sara of today considers herself to be much more informed and educated about Aboriginal culture, history and traditions, having built the framework of her understanding by participating in a good orientation program when she began her current role as the senior physiotherapist at Alice Springs Hospital.
This solid grounding, combined with the experience of working in very remote Aboriginal communities around the mid-west of Western Australia, leads Sara to firmly believe that having an education in Aboriginal cultural awareness is fundamental for all health practitioners living and working in rural and remote parts of the country, to help close the gap in equality in health and Aboriginal life expectancy.
A key component of The National Scheme’s Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020–2025 is around ensuring that non-Aboriginal and Torres Strait Islander health professionals are more adequately equipped to provide effective healthcare for Aboriginal and Torres Strait Islander peoples.
The strategy, which aims to eliminate racism from the health system, noted that changes to the National Law to embed cultural competency and safety have been requested.
And soon the Australian Health Practitioner Regulation Agency (AHPRA) will mandate a level of cultural competency for all health practitioners.
‘Cultural awareness is important in my role to get an understanding of the social determinants of health … things like housing security, and connection to community on land might be more important to Aboriginal and Torres Strait Islander patients than non- Aboriginal and Torres Strait Islander patients,’ Sara says.
‘To get better health outcomes for patients, it is vital to take the time to really listen to their stories, to build rapport, to try not to be judgmental, and to not make assumptions based on your own beliefs.
‘The term referred to is clinical yarning, which is a two-way dialogue. It’s where you’re listening to and telling stories, and picking up things from those stories. You are taking out snippets and putting the picture together. It’s not necessarily in a set format, as you would have a subjective assessment.
'This yarning works better for some of our Aboriginal and Torres Strait Islander people, I believe.’
As the only pain physiotherapist at Alice Springs Hospital, Sara also understands that while pain might be universal, how it is expressed and the beliefs of pain might be quite different and variable in the Aboriginal and Torres Strait Islander population.
This, she says, can influence assessment and management of pain, so that is where a good understanding of cultural safety is important.
‘For somebody that is silent throughout a consult, it’s not necessarily that that patient hasn’t understood you and you have to keep repeating yourself.
'A patient might be nodding at you but it might not be that they’re understanding you, so there’s lots to take on board.’
About 40 per cent of the population of Alice Springs identifies as Aboriginal and Torres Strait Islander and, as it is the regional hub of Central Australia, the town attracts Aboriginal people from all over that region and well beyond.
Many Aboriginal people visit regularly to use the town’s services. Sara says about 80 per cent of the hospital’s case load comprises local Alice Springs residents, with 20 per cent coming from the more remote surrounding areas.
‘We have a cohort of patients in Tennant Creek, which is a town about five hours away,’ Sara says.
‘We cover a lot of remote Aboriginal communities stretching from the Barkly region, where Tennant Creek is, down to the tri-state border of Western Australia, South Australia and the Northern Territory, and as far out west as Kintore, as far east as Lake Nash and as far south as places like Fregon in northern South Australia.
‘With that cohort there are a lot of different language groups such as Arrente, Walpiri, Pitjantjatjara and Luritja to name a few.
'So often when patients are coming in to see us, English isn’t their first language. Instead, it might be their fourth or fifth language; it’s pretty amazing how many different Aboriginal languages there are.’
To help health workers with cultural safety and the many Aboriginal languages spoken, Alice Springs Hospital has Aboriginal liaison officers on staff, who provide specialist skills and are available to assist at any time and be an essential part of the care team.
The Aboriginal liaison officers help provide culturally appropriate support services to patients, including interpreting and family meetings.
As the hospital’s pain service coordinator and senior physiotherapist, Sara’s role is to optimise the pain management care for patients by coordinating multidisciplinary clinics and services for patients.
This involves implementing and monitoring a lot of case management plans, collaborating with other internal specialists in the hospital and external stakeholders where people might be receiving treatment.
Sara also provides her own physiotherapy assessment and management for pain patients.
‘We have about 290 patients on our pain service list at any one point in time,’ Sara says.
‘We also have some visiting specialists from Adelaide that travel here too, and we’ve got two pain consultants located here.
'Ideally we would like to have a psychologist as part of the multidisciplinary team; however, we’re currently not funded for that.
'I think all health clinicians in pain management services are very multidisciplinary in approach anyway. Even physios who don’t work in pain have a bit of psychology on board.
'I’ve had to exponentially learn a fair bit about cognitive behavioural training basics, and acceptance and commitment therapy, and I use those approaches in my treatment of patients as well.’
Sara says a majority of the patients she sees present with conditions such as chronic low back pain, headaches, chronic musculoskeletal conditions, pain conditions (such as post-surgical pain) and some chronic pain sensitisation syndromes such as fibromyalgia and complex regional pain syndrome.
‘I enjoy the complex care coordination. I’m autonomous in my role, so I can take the time to get to know people and understand people, which is important, as well as take the time to understand the issues impacting on their pain,’ Sara says.
‘You need to be holistic. So there’s so many different biopsychosocial issues that can impact on people and their experience of pain, whether it’s sleep, mood, mental health issues, stress from financial and relationship issues, prior addiction issues or general activity levels.
'There are many different facets to getting to know somebody.’
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