Providing Culturally Safe Care For Shakira: A Case Study Essay.

Rheumatic Heart Disease

Shakira is a 7 year old girl living in a remote Indigenous community in the Northern Territory.
She has 2 brothers and 2 sisters between the ages of 3 to 12 years. She is now cared for by different family members in communities scattered over a large area of the NT as her family frequently travels. Her mother Jasmine is 27 years old and has recently lost custody of her children as she was frequently found to be drinking in town and not caring for or feeding her children. Her father cannot be located.

Shakira was diagnosed 2 years ago with Rheumatic Heart Disease and is required to have injections every 3 weeks for at least 10 years as well as follow up cardiac tests. These tests include Echocardiography which can only be done in city hospitals. Shakira started her life underweight at birth and has suffered many middle ear infections leading to decreased hearing which has affected her speech.
Shakira frequently misses school but when she does attend she is fed breakfast to start her day as often food is scarce within the family. She is still underweight for her age.

Research and then provide the following information about Shakira:
1. Briefly discuss Rheumatic Heart Disease and the cause, including factors that may have led to Shakira contracting the disease.
Identify and explain two social determinants of health that may have made Shakira more susceptible to the disease.
Explain how one of these determinants may have affected Shakira’s families decision-making around her care.
Include the standard treatment required
Include relevant Indigenous statistics for RHD compared to the mainstream population. 

2. Explain how you will provide culturally safe care as an Enrolled Nurse by defining and giving one example of the following terms:
(a) Cultural awareness
(b) Cultural sensitivity 

3. By acknowledging the impact of events and issues throughout the history of Australian and Torres Strait lslander people it helps the Enrolled Nurse gain insight into the current physical, mental, social, economic and political situations affecting Australian and Torres Strait lslander people and their engagement with community services and health systems.

3.1 Research via the link: https://www.legislation.gov.au/Details/C2012C00258 In your own words briefly explain the objectives of The Aboriginal and Torres Strait Islander Act 2005. 

3.2 Considering the health generally of Aboriginal and/or Torres Strait Islander people provide an explanation in your own words of the significance of one the following and briefly explain how they may be affecting the day to day health and wellbeing of these people.

(a) The impact of European settlement/Colonisation
(b) Loss of land and culture
(c) Kinship/skin system
(d) Mabo case/ Terra Nullius
(e) Forced removal of children (‘Stolen Generations’) (100 words)

4. Successfully working in partnership with Australian and Torres Strait lslander people requires effective communication. Gaining their full participation by consulting with them and involving the individual and at times the community in their health care decisions is essential to providing culturally safe nursing care.
Select one of the following strategies and discuss how this strategy can assist the Enrolled Nurse to improve communication and build a rapport to provide culturally safe care. 
Consultation with community representatives
(a) Community participation in decision making
(b) Health clinics built in such a way that male and female areas are separate and have separate entrances. Both male and female health professionals are present.
(c) Kinship

5. Considering Shakira, briefly discuss two ways that an Enrolled Nurse could ensure effective communication when consulting with her and her family.

6. A culturally safe organisation consults with Indigenous Australian community leaders and workers. Health services should develop culturally appropriate policies and procedures that provide direction for workers dealing with Indigenous Australian individuals.

Choose one of the strategies below and briefly explain how this would ensure that Shakira and her family would feel comfortable accessing the service.
(a) Employing culturally and linguistically diverse staff throughout the health organisation.
(b) Choose one accessible resource related to a Shakira’s health issues that if available to health employees would assist.
(c) Displaying Aboriginal or Torres Strait Islander art and posters that are clearly visible from the entrance to the building. 

7. By regularly reflecting on situations you encounter in your work practice you will develop your own cultural safety practices. How well do you integrate cultural safety into your practice as a student Enrolled Nurse?

Briefly discuss one of the following questions.
(a) Do you understand how Indigenous Australian culture and history shapes Indigenous Australian people’s interaction with non-Indigenous society?
(b) Do you show you are prepared to re-shape your own values and perceptions to accommodate the needs of Indigenous Australian individuals and co-workers?

8. To evaluate the extent to which cultural safety is integrated in your own work and in your workplace it is a good idea to put yourself in the shoes of an Aboriginal or Torres Strait Islander individual.
(a) List two questions an Aboriginal or Torres Strait Islander may ask themselves when considering if they will access the health service.
(b) List two indicators of a culturally unsafe service.

Rheumatic Heart Disease (RHD) is caused by an abnormal autoimmune response to group A streptococcal infection and causes cardiovascular diseases, especially in younger people (Marijon, Mirabel, Celermajer, & Jouven, 2012).

Social determinants of Rheumatic Heart Disease –

The social determinants of Rheumatic Heart Disease include poverty, malnutrition, and overcrowded housing; which further reflect the health inequities faced by indigenous communities in developed countries such as Australia (Kerdemelidis, Lennon, Arroll, Peat, & Jarman, 2010).

In case of Shakira; poverty and malnutrition has made her more susceptible to disease.

Standard treatment –

The standard treatment requires consultation with a cardiologist, neurologist and rheumatologist. Patients with positive cultures for Streptococcus pyogenes are given penicillin if allergy to penicillin is not present. Alternatively, benzathine benzylpenicillin may be given. Salicylates are helpful for relieving pain. Rheumatic heart failure responds well to corticosteroids in addition to ACE inhibitors, beta blockers, diuretics, and digoxin.

Indigenous statistics for RHD compared to the mainstream population –

Australia has highest prevalence of rheumatic heart disease (RHD) in the world with some 2-3% of the NT Aboriginal population affected by the disease (Co-operative research center for aboriginal health, online).  

Cultural awareness is the initial step to provide culturally safe care and it involves awareness of Aboriginal and Torres Strait Islander norms, values and principles (AIDA, 2013).

Cultural sensitivity is the next step where self-exploration occurs and an individual can take different positions on a continuum, according to setting or community (ibid). The final outcome is the culturally safe care.  

To practice cultural safety while providing care as an enrolled nurse, following points will be taken care of.

• Aboriginal and Torres Strait Islander artwork could be displayed in health-care settings.
• Aboriginal and Torres Strait Islander languages could be used in the health services.
• An association with Aboriginal and Torres Strait Islander individuals and communities must be developed.

Aboriginal and Torres Strait Islander Act 2005 has been formulated; for social, cultural and economic development of Aboriginal persons and Torres Strait Islanders by their full participation, and to develop self-sufficiency and self-management among them, and to ensure co-ordination between state and the islanders while formulating policies (Office of Legislative Drafting and Publishing, 2012).

The term ‘stolen generations’ refers to about 0.1 million Indigenous Australian children who were forcibly removed from their parents and raised by church organisations, fostered or adopted by non-Indigenous families, or given to state institutions; with a mistaken belief that those children were better-off in a non-indigenous social environment (Read, 2014). The forced removal of children had a huge impact on the health and well-being of these children along with the fact that they had no access to their own heritage and culture (ibid). These children offen suffer from malnutrition, RHD and other diseases. It also affects their psychological and mental health and well-being (ibid).

International as well as Australian evidence had suggested the important role of Indigenous community participation for effective healthcare delivery among Indigenous children and families (SNAICC, 2012). Community participation in decision making also ensures a culturally safe lens to view the important role of; family, kinship, cultural values and community ties; in the care and well-being of children. Aboriginal and Torres Strait Islander families have a support system in their community ties, which help them address the challenges of poverty and disadvantage and this ensures community controlled child-welfare and protection (ibid). The decisions regarding healthcare of communities must be effectively communicated to them and should be demand-driven i.e. it should address community needs. The community knows best about their grass-roots health problems and their determinants and hence the community should be represented while designing their health-care programmes.

5. Enrolled nurse must ensure effective communication when consulting with Shakira and her family. The communication should be two-way communication where the nurse should also consider view-points and suggestions of Shakira’s family members as how they can best take-care of her. Enrolled nurse must learn their native language and must communicate in a way; Shakira’s family can easily understand and reciprocate. The nurse should look for social cues while communicating with the family, along with clinical cues; as it would help her in clinical reasoning (Levett- Jones et al, 2010).

6.c. One of the strategies that would ensure that Shakira and her family would feel comfortable accessing the service will be; Displaying Aboriginal or Torres Strait Islander art such as posters that are attractive and clearly visible from the entrance to the healthcare setting. Such a strategy will reflect cultural awareness and cultural sensitivity.

7.b. A nurse should have the ability of clinical reasoning which is more than mere clinical judgement (Levett- Jones et al, 2010). For a good clinical reasoning ability, it is important to integrate cultural safety into the practice. Here, while planning nursing care for Shakira, cultural safety will help re-shaping our own values and perceptions which will further help accommodating the needs of Indigenous Australian individuals and co-workers. The values and perceptions about lives of these communities also re-shape as we work with them. The perceptions about diseases and health states also re-shape as we come to know more social determinants while working in field.

8.a. Two questions an Aboriginal or Torres Strait Islander may ask themselves when considering if they will access the health service will be,

1. Are the health-care services meant for our benefit and care?
2. Are the health-care professionals, one among ourselves, or are they some foreign people imposed on us?

8.b. Two indicators of a culturally unsafe service are,

1. Low OPD (Out-patient Department) rates
2. High pre-mature mortality in the community and high morbidity.

References

Australian Indigenous Doctors’ Association, (AIDA). (2013). Position Paper Cultural Safety for Aboriginal and Torres Strait Islander Doctors. Medical Students and Patients. Canberra: AIDA.

Co-operative research center for aboriginal health, [Online]. Rheumatic Heart Disease Backgrounder. Retrieved from web address,, https://www.lowitja.org.au/sites/default/files/docs/15-RHDMediaBackgrounder.pdf. Lowitza Institute.

Kerdemelidis, M., Lennon, D.R., Arroll, B., Peat, B., Jarman, J. (2010). The primary prevention of rheumatic fever. J Paediatr Child Health, 46(9), 534–48. doi: 10.1111/j.1440-1754.2010.01854.x.

Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Frenchs Forest, NSW: Pearson.

Marijon, E., Mirabel, M., Celermajer, D. S., Jouven, X. (2012). Rheumatic Heart Disease. Lancet, 379(9819), 953-64. doi: 10.1016/S0140-6736(11)61171-9.

Office of Legislative Drafting and Publishing. (2012). Aboriginal and Torres Strait Islander Act 2005. Canberra: Attorney-General’s Department.

Read, P. (2014). Reflecting on the stolen generations [online]. Indigenous Law Bulletin, 8(13), 3-6. Retrieved from web address,https://search.informit.com.au/documentSummary;dn=546123571212449;res=IELAPA.

Secretariat of National Aboriginal and Islander Child Care, (SNAICC). (2012). Genuine Participation of Aboriginal and Torres Strait Islander Peoples in Child Protection Decision-making for Aboriginal and Torres Strait Islander Children: A Human Rights Framework. Melbourne: Secretariat of National Aboriginal and Islander Child Care.