Self-discharge as a marker of surgical cultural competency and cultural safety for Aboriginal and/or Torres Strait Islander patients.

Australian Aboriginal and/or Torres Strait Islander patients experience disparities in surgical access1-4 and outcomes.5-11 Several factors impact the provision of surgical care to Aboriginal and/or Torres Strait Islander people including cultural factors, social determinants of health (social, political and economic factors), historical experiences (loss of land and culture, trans-generational trauma, grief and loss), racism and social exclusion.12 Suboptimal surgical cultural competency and cultural safety may be a contributing factor to these disparities. In the healthcare setting cultural competency is a broad concept describing strategies to improve the accessibility and effectiveness of healthcare for people from ethnic/racial minority groups.13 This includes the ability of healthcare providers, institutions and systems, to incorporate the individual values, beliefs and behaviours of a population into the delivery and structure of healthcare provision.13 Cultural safety encompasses critical consciousness where healthcare professionals and organizations hold themselves accountable, recognizing their own stereotypes, prejudices and biases and working to ensure that they are providing culturally safe care.14, 15 Increasing attention is being paid to healthcare cultural competency or safety and the potential correlation with disparities in surgical care.13 Monitoring cultural competency and cultural safety in the healthcare system is difficult.16 Cultural competency can be measured directly, for example, patient satisfaction or indirectly, for example, self-discharge.16, 17 Self-discharge occurs when an inpatient chooses to leave the hospital before discharge is recommended by their clinicians.18 It reflects a failure to reach consensus between the healthcare staff and patient regarding the need for continued inpatient care. Thus, self-discharge can be utilized as a proxy for measuring healthcare cultural competency and cultural safety. Aboriginal and/or Torres Strait Islander status is the most significant variable contributing to self-discharge.19 Nationally Aboriginal and/or Torres Strait Islander hospitalized patients are six times more likely to self-discharge.19 Rates of self-discharge for all hospitalisations are 3.1% for Aboriginal and/or Torres Strait Islander patients and 0.5% for other Australians.19 Alarmingly there has been an increasing rate of self-discharge over time, from 11 per 1000 in 2004–2005 to 16 per 1000 in 2016–2017.19 This may indicate a lack of hospital responsiveness to Aboriginal and/ or Torres Strait Islander patient's needs.20 One study from the state of Victoria found that 30 % of Aboriginal and/or Torres Strait Islander people have experienced racism in health settings.17 When asked about their experiences with general practitioners in non-remote areas Aboriginal and/or Torres Strait Islander Australians reported that their doctor rarely or never: showed respect for what was said (15%), listened to them (20%) or spent enough time with them (21%).16 Potential markers of cultural competency and cultural safety like self-discharge following a surgical admission have not previously been examined for patients of Aboriginal and/or Torres Strait Islander descent in Australia. Self-discharge is related to increased rates of postoperative complications, mortality,21 readmission21, 22 and increased healthcare expenditure.22-24 These adverse events may be preventable.22 Healthcare staff are commonly concerned that these patients may be susceptible to serious health consequences as the result of not receiving the necessary care.18 The surgical care journey is complex and many different healthcare workers may be involved in patient care. Self-discharge measures the cultural competency and cultural safety along this journey. The reasons for self-discharge are diverse and complex. Qualitative Australian studies have identified several factors related to self-discharge in Aboriginal and/or Torres Strait Islander patients. Patients noted institutionalized racism24 and a distrust of the healthcare system22, 24 including anxiety, anger and negative associations with hospital.25 Family and social obligations,24-26 including financial responsibilities especially on payday,22 pressure from partners and family to return home22 and transport cost and availability (may self-discharge when transport options become available).22 Some patients felt unwelcome or misunderstood25 and that there was a lack of cultural safety.24 Other factors included medical staff that lacked appropriate cultural training,25 behaved in an inappropriate, insensitive or racist manner22 and that there was an absence of Aboriginal and/or Torres Strait Islander staff.22 Social isolation and loneliness were also identified.24, 26 Communication, language and cultural barriers between staff and patients were identified22, 24, 26 leading to miscommunication with hospital staff.24, 26 Patients felt that they lacked an understanding of the care they were receiving,24 felt that the treatment had finished24 or felt that it is okay to leave.26 The patient is always in a vulnerable position in relation to the health care system. Hence it should be an important task for a health care system to take responsibility and adopt to the cultural needs of their patients. However, current rates of self-discharge imply ineffective surgical cultural competency and cultural safety. Quality metrics (standardized measurable indicators) are widely used to assess health system performance and identify areas where quality improvement is needed. Efforts to reduce disparities require metrics that provide the foundation for focused and tailored interventions. Quality metrics are also used to monitor the impacts of a healthcare quality improvement initiatives. There is a lack of validated metrics of surgical cultural competency and cultural safety. Strategies that aim to increase cultural competency and cultural safety may reduce healthcare disparities.13 Intervention strategies include: education and/or training of health professionals or students, culturally specific health programs or resources for Aboriginal and/or Torres Strait Islander people and increasing the number of Aboriginal and/or Torres Strait Islander health workers.12 Increased Aboriginal and/or Torres Strait Islander health workers or liaison officers may be useful in decreasing self-discharge.25, 27 However the care of Aboriginal and/or Torres Strait Islander patients should incorporate the entire health workforce. It is therefore imperative and urgent that cultural competency and cultural safety for the entire workforce should be improved. There is a lack of evidence from rigorous evaluations on the effectiveness of interventions for improving cultural competency and cultural safety in health care for global Indigenous populations.12, 28 Previous studies examining cultural competency improvement strategies in Indigenous populations have not utilized self-discharge as a study end point. The Royal Australian College of Surgeons (RACS) has recently incorporated training on cultural competency and safety into the Surgical Education and Training program and added cultural competency and cultural safety to the RACS Framework. It will be important to assess the impact of this initiative on cultural competency and cultural safety. Self-discharge data is readily available in administrative datasets and could be used as a metric to monitor, benchmark and improve, the cultural competency and cultural safety of a surgical department and possibly also in other specialties. Nationally Aboriginal and/or Torres Strait Islander patients are significantly more likely, than other Australians, to self-discharge. This may indicate suboptimal healthcare, including surgical cultural competency and cultural safety. Self-discharge data is readily available in administrative datasets and could be used as a metric to monitor, benchmark and improve, the cultural competency and cultural safety of a surgical department and most likely also other departments. Elzerie de Jager: Conceptualization; funding acquisition; investigation; project administration; resources; validation; writing – original draft; writing – review and editing. Ronny Gunnarsson: Supervision; validation; writing – review and editing. Yik-Hong Ho: Resources; supervision; validation; writing – review and editing. We acknowledge Prof Yvonne Cadet-James for proofing this manuscript as an Aboriginal and Torres Strait Islander cultural mentor to ensure cultural sensitivity. We gratefully acknowledge the Traditional Owners of the Townsville Region; the Wulgurukaba of Gurambilbarra and Yunbenun, Bindal, Gugu Badhun and Nywaigi people. We pay our respects to their cultures, their ancestors and their Elders, past and present – and all future generations. Open access publishing facilitated by James Cook University, as part of the Wiley - James Cook University agreement via the Council of Australian University Librarians. Elzerie de Jager was a Doctor of Philosophy candidate at an Australian university; this research degree was supported by an Australian Government Research Training Program (RTP) Scholarship. This work was also supported by the Avant Doctor in Training Research Scholarship.