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Objective: This study identified barriers to and facilitators of mental health (MH) and alcohol and drug (AOD) comorbidity services, in order to drive service improvement., Method: Participatory action research enabled strong engagement with community services, including Aboriginal and refugee groups. Surveys, interviews and consultations were undertaken with clinicians and managers of MH, AOD and support services, consumers, families, community advocates and key service providers. Community participation occurred through consultation, advisory and working party meetings, focus groups and workshops., Results: Barriers included inadequate staff training and poor community and workforce knowledge about where to find help. Services for Aboriginal people, refugees, the elderly and youth were inadequate. Service fragmentation ('siloes') occurred through competitive short-term funding and frequent re-structuring. Reliance on the local hospital emergency department was concerning. Consumer trust, an important element in engagement, was often lacking., Conclusions: Comorbidity should be core business of both MH and AOD services by providing consistent 'no wrong door' care. Non-governmental organisations (NGOs) need longer funding cycles to promote stability and retain skilled workers. Comorbidity workforce training for government and NGO staff is required. Culturally appropriate comorbidity services are urgently needed. Despite the barriers, collaboration between clinicians/workers was valued., (© The Royal Australian and New Zealand College of Psychiatrists 2016.)

Background: Aboriginal and Torres Strait Islander people experience inequity in health outcomes in Australia. Health care interactions are an important starting place to seek to address this inequity. The majority of health professionals in Australia do not identify as Aboriginal and/or Torres Strait Islander people and the health care interaction therefore becomes an example of working in an intercultural space (or interface). It is therefore critical to consider how health professionals may maximise the positive impact within the health care interaction by skilfully working at the interface., Methods: Thirty-five health professionals working in South Australia were interviewed about their experiences working with Aboriginal people. Recruitment was through purposive sampling. The research was guided by the National Health and Medical Research Council Values and Ethics for undertaking research with Aboriginal communities. Critical social research was used to analyse data., Results: Interviews revealed two main types of factors influencing the experience of non-Aboriginal health professionals working with Aboriginal people at the interface: the organisation and the individual. Within these two factors, a number of sub-factors were found to be important including organisational culture, organisational support, accessibility of health services and responding to expectations of the wider health system (organisation) and personal ideology and awareness of colonisation (individual)., Conclusions: A health professional's practice at the interface cannot be considered in isolation from individual and organisational contexts. It is critical to consider how the organisational and individual factors identified in this research will be addressed in health professional training and practice, in order to maximise the ability of health professionals to work with Aboriginal and Torres Strait Islander people and therefore contribute to addressing health equity.

Objective: This study described the challenges for rural and remote Aboriginal people requiring transport to city hospitals for tertiary care., Design: Semi-structured qualitative interviews., Setting: South Australian rural and remote health services and tertiary hospitals., Participants: Twenty-eight urban health professionals from six hospitals and 32 health professionals from four rural and remote regions were interviewed. Twelve patients, three carers, four people responding as patient and carers, and one patient and carer couple were also interviewed, with eight elder women meeting as a focus group., Main Outcome Measures: The study identified specific structural barriers in urban health services or policy that prevented rural and remote Indigenous patients from receiving optimum care., Results: Problems accessing transport were identified as the most significant factor affecting access to care by the majority of patients and staff. They reported that travel to an urban hospital was costly, and coordination of travel with care was poor. A further problem was travelling while unwell., Conclusions: Travelling to a city hospital is a significant barrier for rural and remote Indigenous patients. Arranging and supporting travel is a time-consuming work that is not recognised by the health care system., (© 2014 National Rural Health Alliance Inc.)

Background: This paper describes how First Nations Kidney Warriors (Aboriginal and Torres Strait Islander people living with kidney disease), dental hygienists, kidney health care professionals, an Aboriginal hostel accommodation manager and researchers co-designed an approach to improve oral health in South Australia. Kidney Warriors have strong connection to Country, Community and family that underpins health, wellbeing and approaches to research. However, significant colonisation, racism and marginalisation have impacted Kidney Warriors' social, cultural and financial determinants of health, leading to increased chronic conditions including kidney disease. Access to culturally safe, affordable and responsive oral health care is vital but challenging for First Nations Peoples undergoing dialysis and kidney transplantation; Australian oral health care is generally provided privately, in metropolitan centres, by professionals who may hold unconscious bias about First Nations Peoples and incorrect assumptions regarding equal access to care. Methods: The AKction – Aboriginal Kidney Care Together Improving Outcomes Now kidney care oral health working group codesigned strategies to address disparities and gaps in care, and co-create more accessible, responsive, culturally safe and sustainable models of care. A decolonising and collaborative participatory action research was informed by Dadirri Deep Listening and Ganma Knowledge Sharing with repeated cycles of Look and Listen, Think and Discuss, Take Action Together. A small pilot evaluation survey of clinical placement in an Aboriginal setting was undertaken. Results: Four phases of collaboration were undertaken. Community and health professional consultations identified key gaps and priorities. Clinical yarning and cultural safety training and an interprofessional skills day was co-facilitated. Dental hygienist student clinical placement at Kanggawodli Aboriginal Hostel was initiated and evaluated. First Nations Kidney Warriors were positioned as educators and experts of their own lives and health care needs. A new framework for kidney health—oral health cultural safety and clinical education was developed. Conclusion: This codesigned approach involving inter-professional collaboration and joint decision making with community members has significantly informed improvements in oral health care information, services and referral with and for First Nations Peoples with kidney disease. This project provides a working example of how to decolonise health service and education programs from the ground up. Trial registration: NHMRC PAR 2004389. [ABSTRACT FROM AUTHOR]

Cultural safety is increasingly recognised as imperative to delivering accessible and acceptable healthcare for First Nations Peoples within Australia and in similar colonised countries. A literature review undertaken to inform the inaugural Caring for Australians with Renal Insufficiency (CARI) guidelines for clinically and culturally safe kidney care for Aboriginal and Torres Strait Islander peoples revealed a timeline of the emergence of culturally safe kidney care in Australia. Thirty years ago, kidney care literature was purely biomedically focused, with culture, family and community viewed as potential barriers to patient 'compliance' with treatment. The importance of culturally informed care was increasingly recognised in the mid‐1990s, with cultural safety within kidney care specifically cited from 2014 onwards. The emergence timeline is discussed in this paper in relation to the five principles of cultural safety developed by Māori nurse Irihapeti Ramsden in Aotearoa/New Zealand. These principles are critical reflection, communication, minimising power differences, decolonisation and ensuring one does not demean or disempower. For the kidney care workforce, culturally safe care requires ongoing critical reflection, deep active listening skills, decolonising approaches and the eradication of institutional racism. Cultural safety is the key to truly working in partnership, increasing Indigenous Governance, respectful collaboration and redesigning kidney care. [ABSTRACT FROM AUTHOR]

Background: Many healthcare professionals and services strive to improve cultural safety of care for Australia's First Nations people. However, they work within established systems and structures that do not reliably meet diverse health care needs nor reflect culturally safe paradigms. Journey mapping approaches can improve understanding of patient/client healthcare priorities and care delivery challenges from healthcare professionals' perspectives leading to improved responses that address discriminatory practices and institutional racism. This project aimed to review accessibility and usability of the existing Managing Two Worlds Together (MTWT) patient journey mapping tools and resources, and develop new Health Journey Mapping (HJM) tools and resources. Method: Four repeated cycles of collaborative participatory action research were undertaken using repeated cycles of look and listen, think and discuss, take action together. A literature search and survey were conducted to review accessibility and usability of MTWT tools and resources. First Nations patients and families, and First Nations and non-First Nations researchers, hospital and university educators and healthcare professionals (end users), reviewed and tested HJM prototypes, shaping design, format and focus. Results: The MTWT tool and resources have been used across multiple health care, research and education settings. However, many users experienced initial difficulty engaging with the tool and offered suggested improvements in design and usability. End user feedback on HJM prototypes identified the need for three distinct mapping tools for three different purposes: clinical care, detailed care planning and strategic mapping, to be accompanied by comprehensive resource materials, instructional guides, videos and case study examples. These were linked to continuous quality improvement and accreditation standards to enhance uptake in healthcare settings. Conclusion: The new HJM tools and resources effectively map diverse journeys and assist recognition and application of strengths-based, holistic and culturally safe approaches to health care. We have co-designed Health Journey Mapping tools and resources with First Nations patients and families and with First Nations and non-First Nations healthcare professionals to address current gaps in care. These pragmatic, strengths-based tools and resources enhance and incorporate cultural safety, continuous quality and improvement and comprehensive care and can be used collaboratively by healthcare consumers and professionals to assess and improve the quality, access, experiences and outcomes of care. [ABSTRACT FROM AUTHOR]

Patient journey mapping is an emerging field of research that uses various methods to map and report evidence relating to patient experiences and interactions with healthcare providers, services, and systems. This research often involves the development of visual, narrative, and descriptive maps or tables, which describe patient journeys and transitions into, through, and out of health services. This methods corner paper presents an overview of how patient journey mapping has been conducted within the health sector, providing cardiovascular examples. It introduces six key steps for conducting patient journey mapping and describes the opportunities and benefits of using patient journey mapping and future implications of using this approach. [ABSTRACT FROM AUTHOR]

Context The 'inaugural' Caring for Australian and New Zealanders with Kidney Impairment (CARI) guidelines for First Nations Australians provide recommendations on caring for First Nations Peoples with chronic kidney disease (CKD). Informed by targeted national community consultations, the guidelines include the historical context, detailed advice on culturally safe kidney healthcare, screening and referral of CKD. Public awareness and education initiatives, self- management programs, and models of care are all reported on. Objectives The CARI guidelines were developed in response to significant challenges and inequities experienced by First Nations Peoples over many years. Specific recommendations and suggestions aim to improve clinicians' understanding of historical and contemporary factors contributing to the social and health inequities underpinning the over-representation of First Nations Peoples with CKD. These guidelines provide comprehensive support for health professionals in all service and care environments to better respond to the care needs of First Nations Peoples. Key findings The CARI guidelines highlight the need to provide culturally safe clinical care and explicitly cite the need to address institutional racism and improve cultural safety training for all renal service providers. They specifically recognise the importance of kinship, and equitable access to transport and accommodation services. They also focus on keeping people on Country where possible, including increased nurse-supported and Aboriginal health practitioner-supported dialysis services. Conclusion The CARI guidelines provide recommendations on how to improve clinical kidney care delivery for and with First Nations Peoples by ensuring more responsive models of care. [ABSTRACT FROM AUTHOR]

Aboriginal and Torres Strait Islander (hereinafter respectfully termed Aboriginal) people have a greater incidence of stroke at a younger age than non-Indigenous people in Australia. The needs and preferences of Aboriginal people for rehabilitation and longer-term support remain largely unknown. To identify the long-term rehabilitation needs of Aboriginal people who have a stroke, from the perspectives of Aboriginal persons with stroke and health care providers. Aboriginal people who had experienced stroke in the previous three years were interviewed to obtain their experiences of rehabilitation care. Health professionals who provided care in each of six designated hospitals and nearby community health sites were involved in focus groups and individual interviews. Information obtained was thematically analyzed separately for Aboriginal people with stroke and health professionals, and compared using Nvivo. Among six Aboriginal people with stroke and 78 healthcare providers, four main themes emerged: the importance of family; variable access to services; the impact of stroke on Aboriginal peoples' lives; and making positive choices. Communication and involvement of family was highlighted as essential for a shared understanding, particularly when making decisions about participating in short and long-term rehabilitation. Co–morbidities, conflicting priorities, and inadequate or inflexible services and transport compounded issues with changing life roles. Stories of resilience were also shared. Aboriginal people report making positive lifestyle changes, but experience significant unmet rehabilitation needs. Addressing issues of communication, advocacy and flexible delivery should improve some of the shortfalls in service provision, particularly in regional and remote areas. [ABSTRACT FROM AUTHOR]

There are circumstances where ethics overload may be counterproductive to the successful achievement of research outcomes, especially for disempowered client groups. This paper describes and questions the complex time-consuming nature of seeking ethical approval from multiple Human Research Ethics Committees (HRECs) for a comorbidity research project in South Australia. Applications for ethical approval of a major research project involving surveys and interviews of managers and clinicians from mental health and alcohol and other drug services, community advocates and other relevant services were submitted to three major HRECs. Collectively, it took a duration of 10 months to receive full approvals from these HRECs. In addition, a number of Site-Specific Assessments were needed and further approvals were required from multiple Non-Government Organisations (NGOs). Each review process required a detailed application, sometimes followed by lengthy negotiation periods and amendments. These cumbersome, often duplicated processes took a considerable amount of researcher and committee time from a three-year project funding period, thereby delaying the project by almost a year. We discuss the impact of these delays on the timing, progress and potential quality of the research, and on the research team, employed staff, doctoral students involved, and the research budget. We also discuss the additional complexities and inconsistencies of involving two vulnerable populations, Aboriginal Australians and people from refugee backgrounds. This paper informs researchers and funding bodies about this major issue, and offers some suggestions for more effective ethical review processes. [ABSTRACT FROM PUBLISHER]