Cultural competence can increase over time as respectful attitudes are combined with interest and increasing knowledge of the patient’s cultural context. Cultural competence cannot be reduced to a checklist, and education will always be a first step only and a simplification of complex issues.2,3,8,9 Culture varies between different communities of the same ethnic background and changes over time.8 Social factors, such as economic, community and family supports and stressors, cannot be easily disentangled from culture.10 The socioeconomic disadvantage faced by Aboriginal communities today as a result of their history of colonial oppression can be confused as representing their ‘culture’.11
Despite the complexities of what is necessarily lifelong learning around cultural competence, cultural educators and mentors can help GPs and GP registrars to avoid communication pitfalls and provide more culturally competent care.12 Cultural mentoring is defined in GP education as a relationship between an Aboriginal and Torres Strait Islander community member and a registrar undertaking training at an Aboriginal and Torres Strait Islander health training post. This relationship is driven by the Aboriginal and Torres Strait Islander community’s need for culturally safe general practice, and the registrar’s need to receive that knowledge and experience.13 Forms of cultural mentorship and support also occur less formally as Aboriginal people work in partnership with non-Aboriginal healthcare providers.14
The aim of this study was to explore the views of cultural mentors, Aboriginal health workers (AHWs) and other Aboriginal health providers who support or teach GPs and GP registrars working with Aboriginal patients as to what will assist GPs to work effectively with Aboriginal people.
Purposeful sampling was used to select participants for information-rich insights and experience of cultural mentorship and support for GPs and GP registrars.15 Only participants from major cities and large rural towns were recruited, to focus this study on the urban general practice setting. Participation was initially invited through the General Practice Education and Training (GPET) cultural mentor network. Recruitment continued using a snowballing technique15 in which AHWs and educators who had explicit or implicit roles in cultural support and/or mentorship of GPs and GP registrars were invited to participate.
Semi-structured, in-depth interviews were undertaken, lasting 35 minutes, on average, and ranging from 20–50 minutes duration. Participants were asked for their views on key issues that impact on the effectiveness of GPs working with Aboriginal patients and how to support the cross-cultural learning of GPs. Interviews were taped, transcribed and handled using qualitative analysis software (QSR NVivo 10). Exploratory thematic analysis was undertaken, incorporating repeated collection and analysis of data until no new themes were identified.16 The analysis process commenced with coding by two members of the research team followed by team meetings in which the thematic framework was further developed. This allowed increased rigour and reflection through incorporating the complementary perspectives17 of an AHW with extensive experience as a cultural mentor, GPs with longstanding experience working in Aboriginal health and a GP registrar who had received recent advanced training in an Aboriginal Training Post. The identified themes were circulated to participants for review, providing added rigour and further insights. Participants also reviewed this manuscript and the names of those who wished their input to be identified on this manuscript are included with permission.
Fourteen participants were interviewed; 11 were women and 3 were men. They came from a variety of urban and large rural settings in Victoria, New South Wales, Queensland and South Australia. Eight participants worked in Aboriginal community-controlled health services and one worked in an Indigenous health service. Of the other five participants, three had leadership roles within organisations involved in cultural education and mentorship in GP training, one was involved in university level medical education and one worked in a Medicare Local.
What do GPs need to know?
Participant advice to GPs is provided in Tables 1–4. These principles to guide GP care have been categorized into attitudes and approach, communication and consultation skills, culturally aware practices and applied knowledge. A respectful, non-judgmental approach that avoids assumptions about people was considered the most important attribute of GPs who work effectively with Aboriginal people. The need for Aboriginal patients to feel comfortable, respected and safe when seeking healthcare from GPs was paramount. Judgmental and racist attitudes were barriers to therapeutic relationships and were not always recognised by the GPs involved. For example, a medical model which focuses on ‘compliance’ with medical advice was seen as ignoring the complex historical and sociocultural influences that shape patients’ responses to their health and heathcare. Similarly, GPs whose approach to a community was seen as wanting to ‘fix’ their problems lacked awareness of the need to reflect on their own attitudes and approach, to build trust and to learn from the community.
Table 1. Attitudes and approach
|Respectful and non-judgemental
‘They’d rather see a particular doctor because that doctor is, you know, respects them for who they are and actually sees behind [to] who they really are.’
‘Don’t just call them non-compliant because you have no idea what’s happening at home.’
‘GPs have been judgemental…like, “Why haven’t you come here sooner, why did you leave it for this long?”
‘She went into the hospital…But they always assume she’s a drinker. Never had a drink in her life, but it’s that sort of assumption stuff.’
‘Racism is alive and well whether we like to admit it or not.’
|Interest in the community/ individual
‘They’ll know this doctor’s not just here to do his day’s work and go home. He wants to know about us and where we’re from.’
‘Get to know the community when you’re working in it, you know, immersing yourself in it…talk to them, learn a little bit about them.’
|Learn from the community/ establish trust
‘If you don’t earn [the community’s] respect, they’ll say “okay here comes another one, same old, same one, the white knight on the white horse, they come to change but they don’t listen to what we want.”‘
‘Just to be patient. You’re not going to change the world in five minutes or Aboriginal health in five minutes.’
‘I think you have to build a relationship, before you have that conversation with an Aboriginal person…asking questions that are incredibly personal…about sexual orientation, about family.’
|Cultural safety of Aboriginal patients is paramount
‘It’s about the comfort of knowing that you can go there and get good care, and…about general practices thinking about the reconciliation action plan, whatever you want to call it, for their own individual practices.’
‘It is important that you learn how to talk to Aboriginal people because…for our client to be comfortable, that is the utmost, that is the priority.’
|Seek/accept cultural mentorship or advice
'The way the Koori health is at the moment…doctors should have access to Koori mentors in [order to] provide their service to Kooris.’
‘Be open to feedback because I think especially Elders, they don’t mind a bit of feedback, as in… you can’t say that sort of stuff, or, I don’t like it when you do that. I think that’s really important, how they take that, how a doctor takes that.’
‘You know, you’ve got boundaries. You can’t save the world.’
‘They’re coming in to see a professional person, so having that person to be dressed professionally, talk professionally and look professional…[and patients] wouldn’t want them to lower their dress code.’
The importance of good communication and consultation skills was highlighted. These were seen to be similar to those required in all GP consultations, and required respect and management of the patient as an individual in their sociocultural context. Participants highlighted some particular issues that impacted on communication with Aboriginal patients. The terminology around Aboriginal identity was something GPs needed to get right, as use of certain terms, such as ‘part-Aboriginal’, were offensive and would immediately identify a GP as lacking cultural awareness. Appropriate language during the consultation was considered important, not just through limiting the use of medical jargon, but also through avoiding oversimplification of language and assumptions of poor patient understanding, which was regarded as a patronising but common mistake made by GPs.
Participants believed GPs needed to recognise that building rapport and therapeutic relationships could take time. This could be enhanced by allowing adequate consultation time and ensuring follow-up arrangements were in place. Strategies to manage complex consultations and multimorbidities were needed to avoid overwhelming patients and doctors. An approach to consultations in which family members or friends were present, or a child was brought in to see a GP by a member of the extended family, was needed as they were noted to be common consultation models for GPs working in Aboriginal health.
Table 2. Communication and consultation skills
|Good skills in general
‘We do have some patients here that have left the consult unhappy ….one example was that a patient wasn’t happy with the way she was spoken in the consult, and didn’t feel like she was being listened to and wasn’t able to express how she was really feeling.’
‘When people get up and start rushing around, doing other things instead of listening to you, you know that they’re not really interested in you.’
“He was sitting with his back towards the Elder whilst he was talking to the registrar about how incompetent this Elder was with his diabetes…. I think it’s demeaning for anybody, Indigenous or not, to be talking in that manner.’
|Understand rapport and therapeutic relationship building might occur over time
‘Don’t just dictate...build that relationship first.’
‘You can’t just say ‘Has there been any trauma?’…and then just tick the box and go, Okay, thanks we’ll see you later, you know.’
‘Giving them that time, you know, if it takes three appointments to get one thing done, then so be it. Don’t assume that everything’s going to be fixed in the one appointment because it’s probably not.’
|Language appropriate to patient and context
‘I found that the GP… I don’t know what he was thinking, but he was speaking to them like they were really, really stupid, and to me it was quite patronising…they were really dumbing down their language…You need to find a balance using clinical terminology and not being patronising.’
|Adequate consultation time
‘Don’t just rush in and have the consult straight away. Now, I’m going to be a hypocrite, I tell you doctors to hurry up all the time!’
|Strategies for dealing with complex consultations and multimorbidities
‘Like I said to our latest GP registrar the other day, I said, ‘You can’t – Rome wasn’t built in a day. You can’t solve all of their problems in one consultation…a lot do have a lot of complex needs, and in one consultation you can only deal with X amount of stuff’. ‘
|Working with family and friends within consultation
‘No matter what they might think of a 19 year old boy coming in with his grandmother or his mother or his aunt…that’s just the way the family is…and you’ve got to accept that whether you like it or not.’
‘Like, I’ll bring my grandkids in, but might not have [their mother] with them. It’s just how we are and that and they need treatment.’
Knowledge of Aboriginal history, including local history, was considered essential and a learning need that was sometimes underappreciated by non-Aboriginal people. The past and lived history of Aboriginal people was seen to have a strong impact on interactions with GPs and health systems. GPs needed to be familiar with cultural issues that might impact on their patients and their healthcare, and to be aware that these varied between communities. Examples of relevant cultural issues included an understanding of the importance of bereavement or Sorry business, awareness of men’s and women’s business and Aboriginal spirituality, which could be misdiagnosed as mental illness.
Other necessary knowledge included awareness of health problems prevalent amongst Aboriginal people and of how to access specialised health supports and programs that can benefit patients. These include Aboriginal health checks, government initiatives such as Closing the Gap medication support and local Aboriginal services and resource people.
Table 3. Culturally aware practices
|Aboriginal members of staff
‘Definitely employ some Aboriginal people….I can promise you, that is number one.’
‘Employ some Aboriginal staff…Not only will it bring people there, but it will make a difference in say a young girl’s life, to have, you know, a traineeship as a receptionist.’
|Culturally aware staff
‘Get your staff educated; get them to know what’s going on. So when they speak to people, then they know, because it’s not just the GP, but it’s the receptionists, the nurses, it’s all part of the package.’
‘I’ve gone with Aboriginal patients to specialists and the reception was rude…when you walk in and you talk to a specialist, you’re already defensive. So the specialist has lost half of what they should have had.’
|Commitment and skills in identification of Aboriginality
‘What we usually get the practices to say is, “We’re asking this question is to collect this information because there may be unique services that could be provided for this Aboriginal person”.
|Signage in practice
|Acknowledgement of the traditional owners of the land
‘I would have a sign…”This clinic is on Aboriginal land”, and acknowledge the land where you are…It’s not hard, it’s very simple gestures that make a hell of a difference.’
|Practice signs, posters, art work
‘Letting them know that it’s, you know, you are culturally sensitive, maybe putting up some posters and some brochures and flyers.’
‘Yeah, if they see that there…because Aboriginal people are just identifying safe homes, you know.’
Cultural support and mentorship
Participants identified that cultural support or mentorship from local Aboriginal people assisted GPs to work with Aboriginal communities and individuals, and was also important to increase the safety of the community. They saw their roles as being both communication brokers and educators for non-Aboriginal staff. They were able to troubleshoot communication problems if they arose and to advocate for patients and GPs when necessary. Through their local knowledge they provided a specialised type of cultural education, increasing GP awareness of local history, patient contexts and community resources and networks. They advised that GPs who wanted to work with Aboriginal communities and be most effective with Aboriginal people needed to seek advice, and accept it when offered, and this would help them become increasingly culturally competent.
Table 4. Applied knowledge
|The history of Aboriginal people and its impact on health and health services/ provider interaction (including the Stolen Generation and local community history)
‘In talking to GPs and practice staff, they wonder why some Aboriginal families have got so much dysfunction in their lives…until they found out what the history is behind that, they have a better understanding.’
‘There was a young lady who was pregnant, a young girl, and [the GP] said something to the mother, like, “Oh, I’d take the baby if you haven’t got anyone to look after it”, and then she was there when that lady was in labour, that young girl, so they were under the impression that she was there to take the baby.’
‘You got to know the history of Aboriginal people and how it was with GPs and the hospitals and things like that, that suspicion is just, it is just a part of it and it’s not so long ago…I’ve heard the doctor say: “Don’t they know how important it is for them to go to hospital?” I’ll say, “Do you know what’s gone on in the past – why they don’t want to go to hospital? It’s not that they want to die, but that fear overtakes that”.
|Cultural issues and protocols, which vary between communities and individuals
‘We can’t pigeonhole the Aboriginal experience Australia-wide… you work in one community, you work in one community.’
‘Listening and taking the advice. Knowing the culture between Aboriginal and Torres Strait, they’re not the same, they’re different cultures, although we are Australia’s people. Looking at men and women’s business, you know?’
‘But don’t put in a single basket that you don’t look an Aboriginal person in the eye.’
|Understanding client in their context
‘There’s much more to being Kooris than culturally…it’s our social background, it’s our status in society, like how our Elders are treated, there’s so much more involved with looking after Koori people than culturally.’
|Use of appropriate terminology (e.g. ‘part-Aboriginal’ and ‘ATSI’ are offensive/ not acceptable)
‘I did get a GP actually call me, “Oh, I’m unsure about this patient, I’m sure they’re a half-caste.” And I said to the GP, “You don’t use that terminology… that’s offensive.” I said, “We’re Aboriginal and Torres Strait Islander People.” I said, “If you would have said that to your patient, your patient would have walked out in disgust.”’
|Health and health system
|Cultural and health
‘She used to talk to her spirits, and the other nurses and the doctors in the ward thought she had mental health issues, but that was her culture… she had certain totems, or animals that are a part of her totem for her family…being in a mainstream system none of that was taken into account and they deemed her to have a mental illness.’
|Awareness and use of programs and resources available to improve health and break down barriers to care
‘I think the clearest thing to get the GPs is that there’s a lot of Aboriginal programs out there now that are assisting the Aboriginal people. They’ve just got to make themselves aware of these programs and try and utilise them.’
‘[If] you want to send them for tests...[ask] “Are you able to get there, you know, and if not, I’m more than happy to arrange for transport. When you get back, can I get you to come in and see me, so we can find out what the results are to see where we can go from there?”’
The value of this study lies in the generous advice given by experienced Aboriginal cultural mentors and health care providers as to principles that can guide GPs to work more effectively with their Aboriginal clients. Respectful attitudes, good communication and consultation skills, and applied cultural awareness and knowledge were all highlighted as facets of culturally competent general practice.
Aligned with the principles of cultural respect and humility, a respectful, non-judgmental approach was identified as a prerequisite to working effectively with Aboriginal people. Cultural safety, as defined by Aboriginal individuals and communities, was the paramount concern of those who provided their views for this project. For this to be possible, healthcare providers must examine their own attitudes and the social, political and historical factors that shape health practice.18 Fear of being seen to culturally stereotype patients can inhibit well-intentioned GPs from feeling able to acknowledge the sociocultural contexts of their patients and how they impact on their health and health experiences, risking an underestimation of the impact of racism as a barrier to care.19 However, if GPs bring a background of knowledge about Aboriginal health and culture into the consultation, they can apply it as appropriate to the context of their individual patient to provide patient-centred and culturally competent care. Even at the most pragmatic level, supporting Aboriginal clients requires knowledge of their Aboriginality and of the programs and supports that are in place to decrease the health disadvantage of Aboriginal people.
Participants noted that many of the attributes of a culturally competent GP, such as respect and good communication skills, apply to all GP–patient interactions. Additionally in this setting, GPs were seen to need specific knowledge about Aboriginal history, culture, Aboriginal health and Australian health systems20–25 to avoid communication pitfalls and to ensure optimum health care for their Aboriginal patients. Support from Aboriginal people with close ties to their community, such as cultural mentors and Aboriginal health professionals, can assist GPs to provide culturally safe and effective care to Aboriginal clients. Gestures within the practice, such as notices acknowledging the traditional owners of the land or Aboriginal posters, can create a welcoming environment for Aboriginal clients and flag GPs’ interest in Aboriginal health. Clearly, however, this needs to be accompanied by culturally competent healthcare provision within the practice.
This research has some limitations. The study focused on the views of a group of Aboriginal people who work with GPs in urban and large rural communities, and cannot be assumed to apply to all Aboriginal peoples or communities. No participants came from Torres Strait Islander communities and local advice would be needed to guide GPs working in this setting.
GPs who want to contribute to closing the gap on Aboriginal disadvantage need to communicate with and provide health services for Aboriginal people in the most effective way possible. A non-judgmental and respectful approach,as well as good communication and consultation skills, are crucial and aligned with the principles of good general practice health care for all patients. However, these attitudes and skills need to be combined with knowledge of the historical, cultural, social, medical and health system factors that impact on healthcare delivery for Aboriginal patients in general practice. Furthermore, access to mentorship or support and advice from Aboriginal people is important to ensure culturally competent practice.
Ethics approval: Aboriginal Health and Medical Research Council 811/11 and University of Western Sydney Human Research Ethics Committee H9254.
The support of the Aboriginal Medical Service Western Sydney and the Tharawal Aboriginal Corporation is noted. Thanks to the cultural mentor participants, including Sonya Cameron, Val Dahlstrom, Joyce Davison, Marlene Drysdale, Jamie Matthews, Mary Martin and Nola White. Dr Dave was funded through General Practice Education and Training, and supported through GP Synergy.
Provenance and peer review: Not commissioned; externally peer reviewed.