One of the major issues in providing high-quality community and RACF care for older Aboriginal and Torres Strait Islander people is the availability of staff who have undergone cultural safety training.4 Many aged care and healthcare workers lack this specific training.
The use of inappropriate language and practices with vulnerable older people discourage Aboriginal and Torres Strait Islander people from using the available services. The financial resources of many Aboriginal and Torres Strait Islander people are very limited, and this hinders the purchase of additional or alternative services.12 Trained healthcare and RACF staff who have successfully completed cultural safety training may be nonexistent or based long distances from the client. The lack of choice in choosing staff members may further discourage seeking appropriate care.
All healthcare and residential care staff who see substantial numbers of Aboriginal and Torres Strait Islander people should complete cultural safety training. Cultural safety training should be made compulsory throughout all residential aged care, and should include an understanding of context and a tailoring of practice with face-to-face training, and regular follow-up and refreshment of training.
The understanding of context includes awareness and respect of the history, background and culture of Aboriginal and Torres Strait Islander peoples. The recent history is one of trauma and dispossession.13 An attachment to land for Aboriginal and Torres Strait Islander peoples is one of the important understandings. The local community of Aboriginal and Torres Strait Islander people is extremely important, and community consultation is often a necessary first step for provision of any service.
Individual communities can differ significantly; not all Aboriginal and Torres Strait Islander peoples have the same culture, language or lore, and each individual is different. This variation in needs has to be accommodated. Tailoring of practice to local community needs and responsibilities can be manifested in many ways; however, an important proactive practical step is to facilitate the employment of trained Aboriginal and Torres Strait Islander healthcare and care workers within RACFs and general practices, as far as possible.
Cultural safety must underpin the provision of all aged care services to Aboriginal and Torres Strait Islander peoples. There needs to be the creation of genuine multidisciplinary partnerships between general practitioners (GPs), Aboriginal and Torres Strait Islander communities, RACF and general practice staff, other specialist medical practitioners and allied health professionals that are based on community consultation (refer to Part B. Collaboration and multidisciplinary team-based care).
There are major consequences of not providing culturally safe care to Aboriginal and Torres Strait Islander peoples. Firstly, patients with high needs will simply not use services perceived as being culturally inappropriate, which may result in further and worsening morbidity, avoidable hospital admissions and early mortality.
Secondly, Aboriginal and Torres Strait Islander people who use services that are not culturally safe will be unhappy and distrustful, which may manifest in several ways (eg behaviours of concern in the patient, angry family members who may not feel safe to visit unless in large groups). This in turn causes further breakdowns in the relationship between the patient, family and care staff.
Healthcare and care workers may be required to augment traditional roles or allow clients to accept ‘risks’ in order to adequately tailor services. For example, these risks may include participation in important cultural practices while the patient is unwell, and allowing suboptimal personal care by untrained family members. These risks should be taken after appropriate consultation with community and family members and the wider multidisciplinary healthcare team.
When care for an older person can no longer be provided by family and community services, the decision for residential care is significant, particularly if the older person needs to move away from their Country or place. For older Aboriginal and Torres Strait Islander people, a feeling of wellbeing encompasses family, culture, community and Country. Factors such as respect, sense of Eldership, spirituality and feeling safe and secure are integral in facilitating wellbeing at the end of life, and can be particularly challenging to meet in residential care. In addition, many older Aboriginal and Torres Strait Islander people are from the Stolen Generation, and may hold particular memories regarding previous institutional care, and a trauma-informed approach to care is essential.
Talking about death and dying requires knowledge around local customs and traditions that will vary across diverse cultural and language groups. There are varying customs and traditions attached to death and dying that need to be taken into consideration by communities and professional carers. There are useful culturally appropriate guides to assist with discussions of advance care planning that should be considered by healthcare professionals, carers and communities (eg Palliative Care Australia). For those who work in residential care, cross-cultural training and liaison with family and cultural advisors about the older person’s needs are essential.