MiXed Messages

Chapter One:

INTRODUCTION

ABORIGINAL HEALTH ORGANISATIONS operate in a complex cross-cultural environment. Within each Aboriginal health organisation, Aboriginal and non-Aboriginal health workers, who are managed by both Aboriginal and non-Aboriginal staff, provide health services to people in Aboriginal communities. The managers of the organisations report to a managing board or council members who represent the health interests of the people in the communities they come from. Cross-cultural communication issues that affect service delivery and health outcomes can emerge within and between all of these groups of people.

This book investigates cross-cultural management processes in two community controlled Aboriginal organisations (one urban and one remote). The author or Aboriginal co-researchers interviewed forty-five current or past staff from these organisations (27 Aboriginal and 18 non-Aboriginal). Interview data was analysed and interpretations of the results clarified and discussed with key informants. Tentative results were then presented and discussed further in workshops with separate groups of Aboriginal and non-Aboriginal staff. Drafts of the subsequent text were read by a number of critical readers and the final text takes their comments into account.

Information gathered during the interviews with Aboriginal and non-Aboriginal managers indicates that they need quite different but related cross-cultural skills. Non-Aboriginal managers mentioned the importance of a non-judgemental attitude towards Aboriginal people. They must allow for the ways in which direct criticism can discomfit Aboriginal staff, and they must learn how to ‘read’ and use non-verbal and indirect communication strategies. For Aboriginal managers and staff, a key cross-cultural expertise is their ability to deal with the sometimes negative attitudes and judgements of non-Aboriginal people.

Some of the negative attitudes and judgements, which emerge among both groups, appear to be the result of important differences in communication styles.

A mutual unfamiliarity with the different styles of communication found within each group contributes to the development of culturally derived communications problems. It serves to create an environment in which cross-cultural managers face more complex and demanding tasks than equivalent managers in mainstream organisations do. These communication issues can make cross-cultural management a highly stressful activity.

Aboriginal community controlled health services

Aboriginal community controlled health service are culturally appropriate, autonomous primary health services initiated, planned and governed by local Aboriginal communities through their elected Aboriginal board of directors. While they are predominantly funded by government, they are not government run. They are the practical expression of Aboriginal self-determination in Aboriginal health. (Hunter et al 2004:337)

Aboriginal communities around Australia have been establishing Aboriginal community controlled health services since 1971. There are now more than 100 of them, with 51 in remote areas of Australia (Hunter et al 2004). Vastly better Aboriginal health outcomes are possible with community controlled and managed primary health care services (Ring & Firman1998) and there is strong evidence that mainstream health services often do not provide an adequate or equitable level of health services to Aboriginal people, for example Cass et al 2003.

Aboriginal community controlled health services are underpinned by the principle of self-governance. Each health service is based in, and controlled by their community. They deliver holistic and culturally appropriate primary health care. Decision-making is expected to rest with the Aboriginal people, and not with government or any other external agencies.

Despite this, Aboriginal health organisations are subject to the checks and constraints associated with government funding streams and community directed priorities. They have to comply with the rules associated with government funding programs, and cope with variations in funding policies and programs, while seeking to deliver results through an operating framework that reflects Aboriginal values and priorities. In these circumstances, each Aboriginal health agency is a continuously evolving amalgam of differing cultural views and ways of doing things. The managers and staff often deal with conflicting views on priorities and ways of making things happen. They must also account for the use of funds delivered through government funding bodies.

As a result, there can be constant tension between the attempts of a community to control its health service and the constraints imposed by government funding sources. Wakerman, Matthews, Hill & Gibson (1999:73) note that Aboriginal managers are well aware of the illusion of self-management engendered by reporting to Aboriginal boards and governing committees, whilst still accountable to mainstream bureaucratic funding bodies. The funding program guidelines and associated fiscal constraints imposed on Aboriginal health organisations by central funding bodies tend to reflect ‘mainstream’ priorities and management structures.

Shannon, Wakerman, Hill, Barnes, Griew & Ritchie (2003) point out that health innovations only thrive if they conform to the priorities of existing Commonwealth government health policy frameworks. Any innovation that is not located within the current policy framework, no matter how successful, is unlikely to be supported. The resulting interdependence between Aboriginal controlled health agencies and government funding bodies results in both collaboration and antagonism between the two.

Despite these tensions there is a high level of agreement across all levels of government and among the Aboriginal people themselves, that Aboriginal control over health services is the one and only path to improved Aboriginal health outcomes. While the structures, policies and processes of the health organisations may be constrained by the conditions associated with funding agreements and other processes, both Aboriginal and non-Aboriginal managers working within the Aboriginal community controlled health system have a responsibility to facilitate as much Aboriginal influence over the health service as possible. This is the crucial ingredient missing from mainstream health services, and an important key to better Aboriginal health outcomes.

Wakerman et al (1999:67) point out that Aboriginal community controlled health services are open systems and that Aboriginal cultural values affect each workplace because Aboriginal Health Workers reflect the values and priorities of their local community and culture. Aboriginal communities exert their influence on the health organisation not only through representation on the governing council or board, but also through the Aboriginal Health Workers who are drawn from the community, and through other local people employed within the services, including managers. Harris (2002) defines a health service manager as someone who works for a health service and who gets things done though other people. That is, managers organise and support people to achieve the goals of the organisation.

Management processes in Aboriginal controlled health agencies occupy a ‘middle ground’ in a larger system that includes health funding agencies and the Aboriginal communities who use their services. This book addresses the cross-cultural issues in play on this middle ground. It does not seek to explore the interplay of cross-cultural issues between health agencies and funding bodies within each Aboriginal community. It examines some of the processes of social interaction that affect cross-cultural management as well as some of the more notable patterns among the relationships and issues encountered by cross-cultural managers.

Management issues in Aboriginal health

There are many issues that typically arise in cross-cultural environments, and especially in the context of remote Aboriginal health care. Aboriginal communities in remote areas are unique. They are the only places in Australia where Aboriginal people form the majority of the population. Aboriginal cultures dominate in these settings, and non-Aboriginal people and cultures are in the minority. For some non-Aboriginal managers and health service providers, this may be their first experience of the reduced power and influence that accompanies minority status. It may take a period of time to adjust to, and become comfortable with this situation.

Many of the factors affecting Aboriginal health at the national level are particularly evident in remote Aboriginal communities; poverty, overcrowding, and high levels of preventable morbidity and mortality. Generally, there is a poor match between the burden of illness borne by Aboriginal people (demand) and the level of health services provided to meet this need (supply). This is most marked in the remote areas of Australia. Often there is only one primary health service to meet the broad spectrum of health needs across the community. In urban or rural towns of comparable size, there is usually a private GP in the town, a hospital nearby, a chemist, a radiographer, and an ambulance service, among other things. In remote areas, small teams of health workers and nurses are expected to provide all of these services themselves, without access to the usual range of back-up resources. This is a big task.

Remote health services tend, therefore, to operate under a great deal of pressure. They are trying to achieve positive health outcomes without necessarily having access to the resources needed to do this. Many Aboriginal health issues are also very complex ones. They are inextricably tied in with the history of dispossession and the enduring impact this has had on Aboriginal health and wellbeing. This history and its impact on individuals, families and communities varies, in accordance with individual state and territory policies and history and the effect these had at a local level. Each community will have a different story and a different legacy. It is important that managers of community controlled health services know something about the local history and experience of colonisation – this can help them to understand some of the local sensitivities and vulnerabilities in relation to the planning and implementation of health services.

Aboriginal health: a high pressure environment

TRAUMA AND SECONDARY TRAUMA

Unfortunately trauma and secondary trauma are inevitable experiences for those who choose to work in Aboriginal health. This is due to many factors. The legacy of colonisation aside, in remote health services health workers face a higher risk of trauma as a result of the work they do, and they may be psychologically overwhelmed by it.

In cities or large towns, it is unusual for a health service worker to find that they must provide acute or emergency care to someone they know, or to a relative. Also, the people who provide acute or emergency services are not usually involved in the provision of primary health care services, where relationships are necessarily established between the provider and the client. Remote areas are one of the few settings where individuals are expected to provide a broad spectrum of health services to people they know, or get to know, and then must also provide emergency or life saving services when this is necessary. Trying to prevent the death of someone they know (or are related to) is not the same as the provision of emergency services to a stranger – it is a different psychological experience. If a positive outcome cannot be achieved, this is likely to have a direct effect on the health care provider, as well as on the patient’s friends and family.

Good human resource management and staff support are also particularly important in remote areas. In these places, health care workers tend to be over-stretched and under-resourced, and to work in extremely complex psychological environments where they are vulnerable to the whole range of human emotions that come with the task of providing health services to people they know and to their relatives. If they do not receive the additional support they need to do this they are likely to tire, lose their psychological resilience (ability to bounce back), and they may ‘burn-out’. This can mean that they are more vulnerable to the psychological impact of traumatic events when these do occur. Good management support and a great deal of flexibility in individual work arrangements are essential in remote areas, if staff are to stay strong and functional in their roles.

This is particularly so for the local Aboriginal people who provide some of the health services. Intense and prolonged exposure to distressing events involving the illness and death of people they know or are related to, will inevitably take a toll on their peace of mind. That fact that many of the illnesses and injuries they face are preventable only serves to increase the psychological pressures that health staff must deal with. Managers need to be aware of this and the effect it can have on local Aboriginal staff – it is not ‘usual’ or expected exposure in any other health setting, but it is the norm in small remote communities.

However, non-Aboriginal service providers are also vulnerable to these pressures. They too can be affected by trauma and secondary trauma, and especially so when they develop close relationships with members of a community (Kelly 1998; Howard & Ferguson 1999).

Managers of remote health services need to be mindful of the extent of trauma that staff may have experienced and are experiencing, at both first and second hand. Managers need to know about recovery processes and how reactions may diminish performance and affect reactions to workplace conflict. The Bush Crisis Line best practice guidelines (Kelly, 1998) set out important steps that managers can take to support staff who must deal with trauma.

• Support and debriefing should be offered, but group debriefing sessions should not be used in remote settings as these are not appropriate in small close knit communities.

• Regular and predictable periods of rest should be available.

• People are more