Abstract
Objective:
This article explores the role of professional values and the culture of the Australian health care system in facilitating and constraining the implementation of an Aboriginal health policy.
Methods:
Thirty-five semi-structured in-depth interviews were conducted in a case study on the implementation of the Northern Territory Preventable Chronic Disease Strategy (PCDS).
Results:
PCDS included three major evidence-based components - primary prevention, early detection and better management. The research revealed that PCDS changed as it was implemented. The values of the medical and nursing professions favoured the implementation of the clinically-based component of PCDS - better management. But there was dissonance between the values of these dominant professional groups and the values and expertise in public health that were necessary to implement fully the primary prevention component of PCDS. While Aboriginal health workers have valuable knowledge and skills in this area, they were not accorded sufficient power and training to influence decision-making on priorities and resources, and were able to exercise only limited influence on the components of the PCDS that were implemented.
Conclusion:
The findings highlight the role that a myriad of values play in influencing which aspects of a policy are implemented by organizations and their agents. Comprehensive and equitable implementation of policy requires an investigation and awareness of different professional values, and an examination of whose voices will be privileged in the decision-making process. If the advances in developing evidence-based, culturally-appropriate and inclusive policy are to be translated into practice, then care needs to be taken to monitor and influence whose values are being included at what point in the policy implementation process.
Introduction
It is widely recognized that Aboriginal Australians experience higher rates of morbidity and have an average life expectancy 17 years shorter than non-Aboriginal Australians.1,2 These differences have persisted for decades despite a range of efforts on the part of Australia's health care system to reduce these unacceptable gaps. The lack of progress in reducing the gap in health and life expectancy between Aboriginal and non-Aboriginal Australians points to the need to examine the health sector's structures, processes, policies and services, and to identify and adopt the changes that are necessary to improve Aboriginal health.
In theory, mainstream publicly-funded health services are expected to be responsive to the needs of Aboriginal Australians. 3 In practice, despite principles of universal access, many structural, cultural and communication barriers exclude Aboriginal people from accessing many ‘mainstream’ services in Australia.4,5 Aboriginal community-controlled health services were established to address some of these barriers to effective service provision, and, while not available to all communities, constitute a significant component of the health care system for Aboriginal Australians.
The implementation of the Northern Territory Preventable Chronic Disease Strategy (PCDS) was selected as a case study to explore the pathways, facilitators of, and barriers to, policy implementation in a complex health system. PCDS was developed to reduce the incidence and prevalence of chronic diseases across the whole population of the Northern Territory. The empirical findings from this research demonstrate how professional values influence policy implementation. We argue that assessing organizational subcultures will be an important prerequisite to implementing policy. Before exploring the influence of professional values, or in other words, organizational subcultures, on the implementation of Aboriginal policy, these concepts are discussed and defined.
Culture and implementation
Much work has been done to explore the culture and climate of health care systems. This is both a testament to the important influence culture has on the ability of the health care system to provide effective health care and to the difficulty in precisely defining culture and attributing its influence on practice.6–8 Culture refers to collective ways of believing and behaving, these actions and thoughts are dynamic and emergent, rather than fixed or static. 9 However, they are built up and reinforced by formal structures and boundaries, such as professional groups. 10 All occupations, professions, departments, organizations and systems will have their own dynamic and interacting cultures. In some cases these cultures will complement one another, in other cases opposing cultures and values will create either conflict or deeper insight into complex problems. For the purposes of this paper, organizational culture is seen as the culmination of multiple interacting professional values.
Despite the far-reaching influence that culture has on people's actions, more often than not the influences of a dominant culture are not formally recognized nor at the fore of most people's minds. 11 It is not common for people to see, let alone reflect on or critique, the role that the culture of the health care system and their own professional values have on how they define health problems, and how they shape their expectations and understanding of patients’ circumstances. In most situations it is easier to critique the culture of others – of patients or other professional groups – rather than one's own culture and to define ‘the other’ as deviant or non-compliant when there are strong differences.
The hypothesis of this paper is that dominant system values subvert and privilege certain professional groups and undermine others. If particular aspects of policy are not supported by the dominant culture then the comprehensive implementation of policy can be jeopardized. We argue that strategies, such as addressing the underlying determinants of health, are more difficult to implement because they are overridden by the dominant and powerful system values of acute care and Westernized ways of understanding illness.
Methods
This is a qualitative study based on in-depth interviews with a purposive sample of frontline health professionals involved in health policy development and health service provision in the Northern Territory. The sample was intended to deliver a range of perspectives from the workforce across all levels of the health system including central policy-making and health service delivery organizations. Rather than including perspectives across all geographic locations, emphasis was placed on including perspectives from all professional groups within a selected number of geographical locations. Perspectives of doctors, Aboriginal Health Workers and nurses were sought in each location. The study was approved by the Top End and Central Australian Human Research Ethics Committees.
Semi-structured, in-depth interviews were conducted with 35 participants. The interviews occurred at the participant's place of work and the settings encompassed Darwin and Alice Springs and remote Aboriginal communities located several hundred kilometres from the major centers of the Northern Territory. Participants were asked to describe: how they were involved in the PCDS; factors that supported the implementation of PCDS; barriers to implementation of PCDS; how to recognize success; and how to recognize success for Aboriginal people. The duration of the interviews was between 30 and 90 minutes. Thirty-four of the interviews were recorded and then transcribed. One interview was not recorded, but detailed notes were taken. All participants were sent a copy of their transcript (or notes from the interview when not recorded) for verification and comment.
Interview transcripts and notes were entered into QSR NVivo, a computer software package that assists in managing qualitative data. Interviews were analysed thematically. Four themes emerged as influencing policy implementation: health professionals’ values; funding; leadership and management; and workforce. The current paper focuses on health professionals’ values and their influence on implementation.
Results
PCDS evolved and changed as it was implemented. The PCDS was developed in 1997, and endorsed as core business of the Northern Territory Department of Health Community Services in 1999. 12 The PCDS included three major components – primary prevention, early detection and better management. The inclusion of each component was based on evidence that these interventions (separately and combined) were necessary to reduce the incidence and prevalence of chronic diseases. The implementation of the policy was intended to be Territory-wide and universal. In practice, the requirements placed on the new funds available for implementation meant that the policy was mainly implemented in remote Aboriginal communities in the Northern Territory. It had been expected that each of the three major components would be implemented equally although not, necessarily, simultaneously. The research revealed that the better management component was implemented by many health services and the early detection component was implemented to a lesser extent. The primary prevention component received substantially less attention.
The professional and personal values of the health workforce and the organizational culture of the health system both influenced, and were influenced by, the policy. The staff who work in the Northern Territory health system include a full range of professionals most of whom are in ‘clinical’ professions whose primary role is to diagnose, treat, and manage diseases and injuries in individual patients or clients who present to the health system. Aboriginal Health Workers, who have clinical training and roles also, often, fulfill roles that include community-based health promotion. With the exception of the Aboriginal Health Workers, the overwhelming majority of health professionals are non-Aboriginal.
This research found that the medical profession dominates decision-making about system-wide priorities and resources, and about individual patient care. This finding is also supported by other research.13,14 In the Northern Territory, nurses also have significant decision-making powers in the many communities that do not have a resident medical officer. The values of these two professional groups, therefore, predominated in the implementation of the PCDS. This meant that there was dissonance between the values (and knowledge and skills) of the dominant professional groups and the values, knowledge and expertise in public health and health promotion that were necessary to implement fully the primary prevention component of PCDS. Although the Aboriginal Health Workers have valuable knowledge and skills in this area, they were not accorded sufficient power to influence decision-making on priorities and resources, and were able to exercise only limited influence on the components of the PCDS that were implemented.
Different professions: different values
In response to questions about barriers to implementing PCDS, interviewees expressed a range of values about who is responsible for Aboriginal health. Aboriginal Health Workers, nurses and doctors viewed Aboriginal health problems differently, identified different causes or determinants of problems, and expressed different perspectives on what actions need to be taken to address the problems effectively.
Aboriginal Health Workers identified the difficulties that health services have in addressing underlying determinants of health as a major barrier to improving Aboriginal health. For example one Aboriginal Health Worker explained a situation where a child presented often to a clinic with sores: ‘This household, kids keep coming in with sores, scabies, and you treat the kids and they go home and a month later they will come back with scabies’. When asked why there was a problem with this particular house, the health worker explained: ‘Well it's overcrowded. It's got dogs around.’
When asked what needed to happen if children kept presenting with the same problem, the health worker explained: ‘You'd have to treat the whole house, which usually happens. But you need to have a look at the house. Who out of the house is getting income? Are the kids going to school? Is the house kept tidy? How many people are living there? But even if you do find all that out there is nothing you can do if it is overcrowded because there are no other houses to split that house up.’
Therefore, it appears that Aboriginal Health Workers are skilled at acquiring and utilizing community knowledge to inform their professional practice. In the example above the Aboriginal Health Worker examines the underlying determinants of health and the family and community responsibilities for addressing chronic or recurring health problems. This has implications for where work is located. It may be that the Aboriginal Health Workers commitment to addressing the underlying determinants of health shifts the location of work outside the clinic environment into the community setting.
Nurses on the other hand, were more likely to express the view that professional boundaries among the various health professionals and between the health professionals and community members were uncertain and hence a barrier to improving Aboriginal health. Many nurses were concerned about where the responsibilities for health care merge, overlap or differ between patients and health professionals. Nurses sought clarity about responsibility for health care and they saw the need for services to develop an integrated set of responsibilities to enable them to provide effective health care. The following comment draws attention to these concerns:
‘A clinic can only do so much, we can show where there are problems but you can't actually change things happening out there, the [food supplied through the] store or people's attitudes [to healthy behaviors]. They might like to just sit around gambling all day, or they might want to smoke.’ (Nurse)
Miscommunication was identified by some participants as a barrier to effectively sharing responsibility for Aboriginal health. There is a perception that Aboriginal Australians and non-Aboriginal Australians have different communication styles:
‘Some people say, yes, yes, yes and then do no, no, no. They say I am interested, you say well take those tablets then and then [they are thrown] in the bin or garden as you go out. Not everybody votes with their mouth. Some people make themselves scarce when you're looking for them… that's just a mechanism that Aboriginal people use, whereas we might just say we don't want to go.’ (Nurse)
The following statement suggests that some nurses feel a degree of frustration towards Aboriginal people's behavior, their reactions to their health status, and their cultural and social circumstances:
‘I think we worry more about their health than they do.’ (Nurse)
While at the macro level there are certain values that are expressed more commonly within professional groups, it is also the case that there are different values with professional groups. The next section of this paper explores differences within professional groups.
Interactions between individual values and professional values
In response to questions about the implementation of policy on managing chronic disease, three different doctors expressed three different understandings of what actions were required and by whom (Box 1). The particular issue of interest was that of patient compliance.
Three examples of doctors’ understandings of how to manage chronic disease among Aboriginal people
Example A
‘Some of the patients have houses, they have proper cupboards and safe places to keep medicines. They have an appropriate number of people living in the house, and they don't have chaos reigning. And at the other end of the spectrum you've got people living without any housing, living in the open with a chronic disease. So in the one circumstance you've got people who are quite capable of going to a pharmacy and collecting prescriptions and having a whole lot of boxes of tablets and taking them at the appropriate times at home. And they've got the literacy skills to do so. And at the other end, you've got people who are illiterate with impaired eyesight living in circumstances where on any particular day the police or the wardens may come and move them on down the river or whatever and they may lose all their possessions at any time. And you've got everything in between, so you need to be sensitive to where people are at.’ (Doctor)
Example B
‘The main barriers are compliance from the patients. Education is extraordinarily difficult. For example, I had a women the other day aged 25, she had a mitral valve replacement two months ago, she has systemic lupus erythematosus… She's got asthma, she's got pneumonia, she was given powerful antibiotic, intravenously for 7 days. When I saw her last week… I suggested another antibiotic… [The next day] I rang the clinic and said how is she, because she was almost suitable to be evacuated. Oh she hasn't started them yet. That surprised me, because I though the staff in the clinic would have given them to her, at least initially. They had impressed on to her that she had to take them, but she couldn't be bothered’. (Doctor)
Example C
‘We've got what we call: a recall safety net… we wait six months and print a list then of all patients, from our health service, with chronic disease who haven't been here in the last six months, and then we go and visit them. And talk to them, and find out why, and try and get them to reengage in the health service… Also the other problem that we really had to get on top of, doctors here started using the medications… as a way of getting patients to come back. So they'd [the doctors] only give someone four weeks of tablets and they'd say I want to see [the patient] them in four weeks, and so they'd only write the script for four weeks. And that meant that when patients didn't come back, they didn't get their tablets either. And we've got [doctors] them to accept they should be writing, like for most people. And if they decide we're too busy, they can't be bothered waiting to see the doctor, at least they are still taking their tablets. So the control had to be taken off the health professional.’ (Doctor)
In Example A, the doctor expressed insight into, and empathy with, the circumstances of Aboriginal people, but saw that patients can comply with treatment fully only when it ‘fits’ their circumstances. The doctor reflects on the fact that the circumstances of each of his patients with chronic disease are diverse and sees one of the responsibilities of doctors as tailoring care according to patient needs and social environments.
In Example B, the doctor perceives that Aboriginal patients are non-compliant because they are not committed to their health. The doctor expressed little empathy for how a 25-year-old patient with multiple medical conditions might be feeling. There was no mention of the patient's social or economic circumstances, or the potential impact her circumstances might have on her capacity to comply with her medication and other aspects of her care. It appears that the doctor did not recognize that the woman may have had other major problems competing for her attention, may not have understood the instructions, or may have been frightened or ashamed to go to the clinic.
A third doctor, in Example C, emphasized the responsibilities of the health service. Recall systems are an important tool to assist in managing patients with chronic disease by reminding health professionals and patients when regular checks such as blood pressure and blood glucose levels are due. The doctor in Example C suggests that recall systems can be used as a safety net rather than as a management tool. This approach empowers the patient to take responsibility and make decisions about their own health, and at the same time focuses on the responsibility of the health service to meet the needs of at-risk patients. The findings from Example C suggest that micro-managing patients centres the control of the chronic disease with the health service and this can be disempowering and harmful for the patient; it also suggests that doctor–patient behavior is intertwined in a complex relationship.
These examples reflect three different perspectives on appropriate treatment, although each professional is apparently implementing the same chronic disease treatment and management policy. These different perspectives reflect different personal values and experiences, and illustrate the differences that these make to the treatment and care offered to patients.
Within professions, differences in values can reflect differences in training. Recent graduate training is likely to be very different to training received 30 years ago. The doctors whose perspectives were included in the three examples in Box 1 were all men of similar age and training, although the doctor in Example B was 10 years older, and had less experience working in the Northern Territory than the other two doctors. It seems plausible, therefore, that experience in working with Aboriginal communities, organizations and patients can lead to a shift in personal values and hence, to a difference in the implementation of clinical policy.
The culture within the health care system
One of the aims of the PCDS was to introduce a new way of managing patients with chronic disease. This necessitated a shift in the culture of the health care system away from treating patients reactively once they present to the health service, towards working systematically with patients in the ongoing management of their chronic disease. This includes strategies such as following up patients routinely every three months. However, as aptly described by one participant, changing the culture of health services is a difficult and time-consuming task.
‘There was a lot of resistance from a lot of the older remote nurses and health workers, to the idea that your job was to run these systems and go out and chase people for follow-up. And before that there was very much a culture of you treated what walked in the door. It is not until you do an audit and you show that someone with diabetes has attended the clinic 50 times during the year and they haven't had a blood pressure or a blood test done, that you can sort of win people over and say… your opportunistic care methods are not working. Because that diabetic will always come in at 9am on Monday morning when the clinic is jam-packed and you're always going to say can you come back on Wednesday and we'll do your blood test and they are never going to come, unless you go out and invite them in on Wednesday. So that culture has shifted.’ (Doctor)
This cultural shift suggests that the better management component of PCDS has been implemented and gives insight into the mechanisms of culture change within the health care system. Multiple steps are required to change the culture of the health care system. Strategies that have been found to be particularly useful include: audits and the provision of other evidence that describe the problem; systems such as quality improvement processes, or patient recall systems to support both patients and health professions in meeting their responsibilities; and leadership that articulates and creates commitment for new values and beliefs.
A potent message emerging from the interviews was that focusing on patients’ compliance with medication over-emphasizes patient responsibility and draws attention away from the circumstances that influence patients’ health, service provider responsibility and government responsibility.
‘The limitations of compliance being seen solely as patients’ responsibility are that it enters into the dangerous territory of victim blaming, it doesn't account for other significant factors such as living conditions, it doesn't account for service provider responsibility such as the extent to which service providers involve patients and patient circumstances in treatment plans, and it doesn't consider the responsibility of government to provide accessible health services and whether or not this responsibility is met.’ (Doctor)
The research found evidence of a cultural shift in the allocation of responsibility for the health of patients – moving from a single focus on patient responsibility to a more comprehensive focus on the responsibilities of health professionals, services and governments. Patients can take responsibility for only one component of their treatment and ongoing management – and can do so only with the active support of the other components of the health care system.15,16
Discussion
The PCDS is an evidence-based attempt to improve the management of chronic disease. However the implementation of the policy is undertaken by doctors, nurses, allied health professionals and Aboriginal Health Workers who view the health problems and their causes differently and who have different perspectives on what action needs to be taken. Despite the unifying values that are taught through professional training, there are also diverse personal values held by individual professionals which may be linked with age, gender, social class or experience. In addition, organizational culture is important because it influences what is privileged in an organization, how things are done, and an organization's performance and priorities. The values (professional and personal) held by professionals can be seen as an important component and manifestation of organizational culture. These values influence the analysis of problems, the selection of solutions, and the evaluation of progress assessed by each of the health professionals involved.
Differences in viewpoints
The implementation of policy is filtered through the values of those responsible for action. Not all values are considered by those responsible for policy implementation to have equal merit in the health care system at all times. Certain aspects of policy are more closely aligned to particular professional values and to the acute care emphasis in the health care system. For example, better management and early detection strategies for chronic disease are based on activity with individual patients, and are more closely aligned with the dominant values and perceived core business of the health care system. Primary prevention, on the other hand, involves working in the community and outside the health sector. Giving priority to primary prevention requires the application of a different set of professional values that, in relation to Aboriginal health, are most closely associated with the values (and experiences) of Aboriginal Health Workers. This, and other, research has shown that policies that do not align with dominant professional values are more difficult to implement. 17
Understanding complex problems and developing comprehensive solutions relies on the consideration of a mix of voices at all stages of the policy process. It is often difficult to be conscious of one's personal and professional values, of the influence they have on the way in which health problems are perceived and on the ways in which different health professional groups within the health system decide which actions are taken first. Generating a process that will support more reflective practice among all health professionals will facilitate the development of a more responsive health care system that is more accessible to Aboriginal Australians.18,19
In some cases, it is difficult to distinguish between the culture of the health care system and the culture of dominant professional groups. There is a history in the Australian health care system of over-emphasizing patient compliance with medication or treatment regimes, and of drawing attention away from the circumstances that influence patients’ health, service provider responsibility and government responsibility.20,21 This history is echoed in the views expressed by many nurses and some doctors interviewed as part of this study. However it is important to note that there are many subcultures and a range of professional values within the health care system. Not all health professionals emphasize patient compliance. But it is difficult for these professionals to operate outside the dominant values and cultures of the health care system.
There is a need to consider the impact of change on specific groups. Which professions will benefit from change and at what point, and which professions will be disadvantaged? These questions are important to both the change process and the comprehensive implementation of policy. In addition they are important to building a healthy workforce and other important components of health system capacity.
The nature of change
More often than not, implementation decisions are made implicitly through the influence of a dominant culture and professional values. Leaving decisions about which aspects of policy are implemented first to the dominant culture will make change slower, more diffuse and patchy. It may mean that change occurs according to the history of the health care system, the preferences of dominant professional groups, or pressure from advocacy groups, 22 rather than being driven by the needs of the population whose health the policy is intending to influence.
The health care system currently values the development of evidence-based and inclusive health policies, at least in principle.23–26 Yet this research suggests that the implementation of the PCDS was influenced by the pre-existing strengths and weaknesses of the health care system, rather than by evidence-based policy goals. An evidence-based implementation process is required to ensure that implementation occurs according to population needs rather than exclusively according to the professional preferences inculcated through the culture and subcultures of the health care system.
Strengths and weakness of the research
A strength of this research was that the PCDS is a live strategy that has been implemented for five years through much of the Northern Territory health system. One of the authors of this paper had played a major role in the development of the PCDS and continues to have a keen interest in its implementation. A range of health professionals working in policy and service provision was interviewed, seven of whom were Aboriginal. A rich range of perspectives on the factors facilitating and constraining the implementation of PCDS was obtained. However, Aboriginal community members were not inter-viewed. It was decided, in light of the history of inappropriate Aboriginal health research,27,28 to focus on the health system contributions to Aboriginal health. As recipients of health services, Aboriginal community members have important contributions to make, however there was a need to limit the scope of the research.
Conclusions
The culture of a health care system is dynamic, powerful and self-reinforcing. On the one hand, the culture of the health care system and health professional values (rather than population need) determine which aspects of policy are implemented. This can limit the potential for change. On the other hand, aspects of policy that are implemented affect the culture of the health care system and health professional values.
A collaborative process that incorporates multiple perspectives is required to overcome the limitations of how and what people see. While considering multiple perspectives is the aim, it is likely that some views will dominate. Therefore, a proactive approach is required to ensure that marginalized voices are considered in a tapestry of perspectives. Incorporating multiple professional values relies on a fundamental shift from unconsciously and incorrectly assuming that the dissemination of information is a sufficient starting point for implementing policies. Rather, a revised approach is required that consciously and actively respects the fact that implementation involves the re-orientation of organizations towards new practices.
Policies that require actions that challenge or at least question the current culture or dominant professional values of an organization or group rely on substantial planning to facilitate change. This will require a step-by-step implementation process that is founded on the insight that implementation of policy is much more than the dissemination of information; it involves an investigation and awareness of different professional values and examination of whose voices will be privileged in the decision making process. If this occurs, it will be an important step towards creating an accessible health care system for Aboriginal Australians that is able to prevent illness as well as manage and treat disease effectively.
Footnotes
Acknowledgements
We would like to thank the participants in the research for their time, honesty and openness during the interviews. In addition we would also like to thank the anonymous referees for their intelligent and helpful comments on an earlier draft of this paper.