Development of the Building Strong

Foundations for Aboriginal Children,

Families and Communities Program

Service Standards

June 2015

LITERATURE REVIEW

NSW Ministry of Health

100 Christie Street

ST LEONARDS NSW 2065

Tel. (02) 9391 9000

Fax. (02) 9391 9101

TTY. (02) 9391 9900

www.health.nsw.gov.au

Produced by: NSW Ministry of Health

Contributors and writers:

University of Technology

Rachel Smith

Angela Dawson

Maralyn Foureur

Cathrine Fowler

Juanita Sherwood

Caroline Homer

It may be reproduced in whole or in part for study or training

purposes subject to the inclusion of an acknowledgement of

the source.

It may not be reproduced for commercial usage or sale.

Reproduction for purposes other than those indicated above

requires written permission from the NSW Ministry of Health.

Suggested citation: Smith, R., Dawson, A., Foureur, M.,

Fowler, C., Sherwood, J., Homer, CSE. 2014, Development of

the Building Strong Foundations for Aboriginal Children,

Families and Communities (BSF) Program Service Standards:

Literature Review, Faculty of Health, University of Technology

Sydney.

© NSW Ministry of Health 2019

SHPN (HSP) 190280

ISBN 978-1-76081-155-6

Further copies of this document can be downloaded from the

NSW Health website www.health.nsw.gov.au

October 2019

NSW Health 1

Table of contents

Executive Summary ___________________________________________________ 2

List of abbreviations ______________________________________________________ 4

Introduction _________________________________________________________ 5

Aims and objectives of the literature review ___________________________________ 5

Background _________________________________________________________ 5

Closing the Gap __________________________________________________________ 6

Building Strong Foundations (BSF) services __________________________________ 7

Methods ____________________________________________________________ 7

Framework used to guide the analysis of literature _____________________________ 7

Search Protocol __________________________________________________________ 8

Inclusion Criterion ________________________________________________________ 8

Findings ____________________________________________________________ 9

The National Framework for Universal Child and Family Health Services __________ 10

Service provision for Aboriginal families ____________________________________ 10

Community development and Community-led design of services __________________________ 11

Specific programs for early childhood ________________________________________________ 12

Specific programs for women during pregnancy and the first few weeks of life ________________ 13

Service Standard Principles _______________________________________________ 14

Defining service standards ________________________________________________________ 15

Justifying the use of service standards _______________________________________________ 15

Structure of service standards _____________________________________________________ 16

Other ways of describing key elements within standards _________________________________ 20

Developing and measuring service standards _________________________________________ 20

Policy and Regulation ____________________________________________________ 20

Policy frameworks _______________________________________________________________ 21

Setting targets in policy ___________________________________________________________ 21

Policy supporting child and family health in NSW _______________________________________ 21

Developing a fit-for-purpose workforce ______________________________________ 22

Influences on the workforce _______________________________________________________ 22

A health workforce that can deliver culturally safe services _______________________________ 22

Capacity building of the workforce __________________________________________________ 23

Clarity of roles, responsibilities and competencies ______________________________________ 23

Conclusion _________________________________________________________ 24

References _________________________________________________________ 25

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Executive Summary

This literature review was undertaken to inform the development of service standards and workforce

strategy for the Building Strong Foundations for Aboriginal Children, Families and Communities (BSF)

programs in New South Wales. The primary aims of the review were to identify current best practice

examples of service standards and workforce and recruitment strategies for the delivery of high quality

services for Aboriginal1 children, families and communities. The review included literature on service

provision; developing, utilising and identifying effective components of service standards; implementing

and evaluating service standards; and, effective human resource processes to support the provision of

best practice health care for Aboriginal children and families.

The context of the review firstly recognises Aboriginal Peoples as the First Australians and respects

the culture of strong connection and community. The review acknowledges the Aboriginal definition of

health as incorporating a whole of life view, where health includes the physical, social, emotional and

cultural wellbeing of communities and individuals. The historical and ongoing impact of colonisation is

recognised and the importance of adopting a strengths-based approach to working with Aboriginal

families is valued.

An integrative literature review was undertaken and involved a structured search and analysis of both

peer-reviewed and grey literature. The search initially generated 148 papers and documents that met

the inclusion criteria and on closer examination 23 of these were considered not relevant. 125 papers

and documents were examined in detail and from this 84 were used to inform the review. Papers and

documents were analysed and discussed in relation to the following broad topic areas;

Service provision for Aboriginal and Torres Strait Islander families

Service standards principles and content

Implementation and evaluation

Policy and/or regulation that inform standards/services

Workforce development

The analysis of papers in relation to service provision for Aboriginal families provided the review with a

summary of evidence-based principles that should be considered when reviewing existing services or

developing new service standards. Evidence-based principles identified in the literature review are

presented in Table 1.

Table 1: Evidence-based principles identified in the literature review

Evidence-based principles that underpin Aboriginal child and family health programs

Ensure community leadership and sustained involvement in the development of the service Consistent with the principles of Primary Health Care Invest in capacity building for sustainability Provide targeted funding for Aboriginal specific services Provide locally accessible and appropriate services for all families Provide a culturally competent service Ensure flexibility in implementation and service delivery Support a strengths-based and family centred approach Provide integrated services Promote high quality communication and collaboration

1 The term ‘Aboriginal’ is not generally inclusive of Torres Strait Islander people, and reference to both Aboriginal and Torres Strait

Islander people should therefore be spelt out where necessary. Within NSW Health, the term ‘Aboriginal’ is generally used in preference to ‘Aboriginal and Torres Strait Islander’, in recognition that Aboriginal people are the original inhabitants of NSW (see NSW Health Circular No. 2003/55). When discussing or presenting national or international literature that uses the tit le Indigenous,

this terminology will be used.

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Whilst not made explicit in the service standards literature, there is an assumption that all care

provided by services for Aboriginal children, families and communities will be based on evidence

where evidence is available, and if evidence is lacking, will be based on expert consensus.

There is increasing interest and use of service standards in health service delivery and health

performance measurement. Despite this, there is limited information available on what constitutes

a service standard. However, there is agreement in justifying the use of standards to monitor and

improve services and to provide standardisation and consistency in service delivery. There is also

agreement in the literature in regard to broad key components required in the development of

service standards for child and family health services and these include being based on strong

evidence, having an accepted theoretical basis, being innovative and having cultural reach.

Service standards must also be supported by strong overarching policy direction and regulation. A

number of NSW state policies were identified that should inform the development of service

standards that meet and support the strategic directions of Aboriginal maternal, child and family

health service provision. Strategies for improving Aboriginal health service provision in NSW

include building trust through partnership, ensuring integrated service planning and delivery,

strengthening the Aboriginal workforce and providing culturally safe health services. In relation to

supporting development of an Aboriginal workforce and providing culturally safe services the

evidence identifies ensuring cultural competence training is a requirement for the entire health

workforce.

An important principle in the development, implementation and evaluation of service standards and

service delivery in Aboriginal health is to ensure a grass-roots approach and sustained involvement

of Aboriginal community leaders and service users.

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List of abbreviations

ACCHO Aboriginal Community Controlled Health Organisations

ACSQHC Australian Commission on Safety and Quality in Health Care

AHEO Aboriginal Health Education Officer

AHW Aboriginal Health Worker

AMIC Aboriginal Maternal and Infant Care

AMIHS Aboriginal Maternal and Infant Health Strategy

AMS Aboriginal Medical Services

BSF Building Strong Foundations

COAG Council of Australian Governments

HCQI OECD Health Care Quality Indicators Project

HPF Health Performance Framework

MGP Midwifery Group Practice

NACCHO National Aboriginal Community Controlled Health Organisation

NPA National Partnership Agreement

PHC Primary Health Care

SNAICC Secretariat of National Aboriginal and Islander Child Care

SMSBSC Strong Mothers, Strong Babies, Strong Culture Program

WHO HSPA WHO Health Systems Performance Assessment Framework

WHO World Health Organization

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Introduction

A literature review was undertaken to inform the development of the Building Strong Foundations for

Aboriginal Children Families and Communities (BSF) program Service Standards. The BSF Service

Standards (BSF Standards) will assist health services, clinical stream directors, managers and BSF

staff to ensure BSF programs are delivered consistently so that they support Aboriginal families,

children and communities so that Aboriginal children have the best start to life, are healthy, and ready

for school.

The BSF Standards will set out specifications and procedures intended to ensure BSF program

systems are culturally safe, reliable and consistently perform the way they were intended to. The BSF

Standards will establish a common language that defines quality and safety criteria; they will be

practical, outline achievable goals and be based on best practice evidence where available or by

consensus of relevant clinical/content and Aboriginal family experts.

It is important that evidence informs the BSF Standards and the workforce strategy developed as part

of this project. Identifying the evidence is therefore the focus of this document.

Aims and objectives of the literature review

The aim of the literature review was:

To identify current high quality evidence and published best practice examples to assist in the

development of service standards for the delivery of high quality family centred health services

for Aboriginal children and families

To identify evidence and published best practice examples of workforce and recruitment

activities that can assist to ensure the BSF services provided are culturally safe, reliable and

consistent services for Aboriginal children and families

There were a number of specific objectives. These were:

1. Review the evidence relating to the effective provision of services for Aboriginal families

2. Identify the principles that underpin the effective provision of services to these children and

families

3. Investigate the principles that underpin best practice service standards generally, and more

specifically in relation to child and family health services

4. Examine what constitutes the most effective structure and components of service standards

5. Identify relevant policies and regulations that will inform the development and implementation

of service standards

6. Explore the processes involved in the development, implementation and evaluation of service

standards generally, and more specifically in relation to child and family health services

7. Identify factors that contribute to developing a fit-for-purpose workforce in relation to the

provision of child and family health services for Aboriginal children and their families

8. Examine the most effective human resources processes to support, develop and assess

individual and team performance against service standards

Background

Aboriginal Peoples are recognised and respected as the First Nation Peoples of Australia and as such,

like other Indigenous Peoples, have a strong affinity with the land and all that live on it. Aboriginal

Peoples had a strong, sustainable and healthy livelihood up until colonisation and this can in part be

attributed to their traditional view of health. The nationally recognised definition of Aboriginal Health

refers to health as:

‘…not just the physical wellbeing of an individual but refers to the social, emotional and

cultural wellbeing of the whole community in which each individual is able to achieve their full

potential as a human being, thereby bringing about the total wellbeing of their communities. It

is a whole of life view and includes the cyclical concept of life-death-life’ (1).

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It is neither possible nor respectful to discuss Aboriginal health without firstly recognising the positive

impact that Aboriginal Community Controlled Health Organisations have had on Aboriginal health

outcomes since their advent in the early seventies. Local Community control of health is important for

Aboriginal Peoples as it promotes an Aboriginal model of health and wellbeing and promotes self-

determination. Aboriginal Community Controlled Health Organisations are exemplars of a primary

health care model and are administered by Communities, in Communities and for Communities. They

ensure a grass-roots approach to planning, delivering and evaluating health services and promote

community engagement and integrated service delivery that is effective and culturally competent for

that particular Community (2).

The Australian Government recognises that ‘dispossession, interruption of culture and

intergenerational trauma have significantly impacted on the health and wellbeing of Aboriginal and

Torres Strait Islander people’ (3p10). Previous failure to recognise the impact colonisation has had on

Aboriginal peoples has contributed to the myth that Aboriginal Peoples are somehow responsible for

the poor states of health found in some Communities. A continued focus on poor states of health and

disease has in turn created a ‘problem to be solved’ and has led to a deficit-based approach to

improving Aboriginal health outcomes (4). A focus on deficits in relation to health and wellbeing of

Aboriginal Peoples has prevented developing an understanding of cultural and community practices

that support and strengthen Aboriginal health. In relation to Aboriginal child and family health, a deficit-

based approach has pervaded health interventions and historically there has been little recognition of

the strengths and resilience of Aboriginal childrearing practices. The interventionist approach has failed

to recognise the importance of community engagement, cultural respect and community partnership in

effecting positive health and wellbeing (5).

Closing the Gap

In relation to improving health outcomes the terms ‘closing the gap’ and ‘close the gap’ are now

synonymous with Aboriginal Health and despite popular belief, the closing the gap strategy was not

developed by the Government. In 2006, the National Indigenous Health Equality Campaign which

comprised of a number of organisations including the National Aboriginal Community Controlled Health

Organisation (NACCHO) and Oxfam Australia used the phrase ‘close the gap’ for its publicity campaign

in regard to the inequality in life expectancy (6). This bringing together of prominent organisations

committed to addressing inequalities in Aboriginal life expectancy prompted the Council of Australian

Governments (COAG) to commit to and be accountable for ‘closing the gap’ within a specific

timeframe. In addition to addressing inequality in life expectancy in one generation COAG also

publically committed to increasing access to early childhood education, halving the gap in infant

mortality and reading, writing and numeracy achievement by 2018, and halving the gap in year 12

achievements by 2020 (7).

Since the Closing the Gap awareness campaign in 2006 and the COAG adoption of targets in 2008,

numerous strategies and actions have been implemented in an attempt to address the gap. One of

these strategies is a National Partnership (NP) between State and Territory Governments aimed at

improving Indigenous early childhood development services and outcomes (8). The Indigenous Early

Childhood Development (IECD NP) has direct relevance to the Building Strong Foundations (BSF)

program in New South Wales. The BSF program is entirely funded by the NSW government. Funding

for the program contributes to commitments made by the NSW Government under element three of the

IECD NP.

The Indigenous Early Childhood NPA has three priority areas (also known as elements). These are:

1. Integration of early childhood services through children and family centres;

2. Increased access to antenatal care, pre-pregnancy and teenage sexual and reproductive health;

3. Increased access to, and use of, maternal child health services by Indigenous families.

The IECD NP ceased on 30 June 2014, however the Commonwealth government has made

commitments in the 2014-15 budget to continue funding for the element three ‘New Directions program’

and extend funding for 12 months to element two priority area.

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Building Strong Foundations (BSF) services

NSW Health has designed, developed and implemented BSF services. BSF is a primary health care

model of care, with Aboriginal Health Workers and Child and Family Health Nurses working in

partnership to provide a strengths-based approach to early childhood health for children from 0–school

entry and their families. The program aims to promote health and wellbeing, support parenting,

enhance community development, identify health, development and wellbeing concerns, and provide or

refer children and families for early intervention to ensure children have the best possible start in life

and are school ready (9-11).

This model is consistent with the Supporting Families Early policy suite, Aboriginal Maternal and Infant

Health Services (AMIHS) and Families NSW principles and is based on the ecological systems theory

of child development (11). The BSF Program promotes culturally appropriate and safe clinical practice

based on sound evidence, knowledge and skills. It closely interfaces with Aboriginal maternity

programs especially the NSW Health Aboriginal Maternal and Infant Health Services (AMIHS) (9-11).

The BSF services are delivered by Local Health Districts and an Aboriginal Community Controlled

Health Service (Albury Wodonga) and are overseen by NSW Kids and Families (NSW K+F).

This literature review was undertaken to seek evidence to support and inform the development of

service standards for the Building Strong Foundations for Aboriginal Children, Families and

Communities programs in New South Wales. The BSF Standards will set out specifications and

procedures to ensure BSF systems are culturally safe, provide high quality evidence based clinical

care that is reliable and provided consistently the way they were intended. The BSF Standards will

support the establishment of a common language that defines high quality and safe service provision.

The BSF Standards need to be practical, outline achievable goals and based on best available

evidence or by consensus of relevant experts where there is no clear evidence available.

Methods

An integrative literature review was undertaken and involved a structured search and analysis of both

peer-reviewed and grey literature. Although there is no standardised format for integrative literature

reviews it is recognised that results of the search are arranged and critically discussed by relationships

and not by chronological order. An integrative review commences with a conceptualised structuring of

the topic so that literature relationships can be identified prior to the review and these serve to provide

a framework for the review (12).

Framework used to guide the analysis of literature

The development of relevant, evidence-based and practical service standards for BSF programs

necessitated a review of a broad range of literature. To ensure the review was undertaken in a

systematic way a framework was developed to guide the literature search and the analysis of the

retrieved documents. This enabled the findings to be presented in a coherent manner.

The framework (see Fig. 1), captures elements that constitute the content of service standards,

processes involved in implementing and monitoring them, the associated outcomes and human

resource aspects associated with their delivery. Mapping the elements of service standards in this way

provides a framework to describe the findings of literature in order to determine how standards are best

delivered and quality and relevance assured.

Conceptualised structuring of literature relationships also assists in the identification of knowledge

gaps and areas that may require further exploration.

The literature framework spans a number of inter-related topic areas which are graphically

demonstrated in Fig.1.

Figure 1: Interrelationships amongst literature review topic areas

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Search Protocol

A systematic search of the literature was undertaken using 6 bibliographic databases (Indigenous

Collection (Informit), MEDLINE, Academic Search Complete (EBESCO), SCOPUS (Elsevier),

PubMED, and Health Business Full Text Elite (EBESCO)) between 2004 and 2014. In addition, Google

Scholar was used to search for grey literature such as Government and non-Government reports,

evaluations, policies and regulatory documents. In an effort to identify key Aboriginal health

publications and resources websites such as SNAICC (Secretariat of National Aboriginal and Islander

Child Care) and the Closing the Gap Clearinghouse were searched. A further hand search of

references used to inform the grey literature was undertaken.

The following search terms were used in bibliographic databases to locate relevant documents:

‘service standards’, ‘health service’, ‘early childhood’, ‘Aboriginal’, ‘Aboriginal and Torres Strait

Islander’, ‘Australian Indigenous’, ‘quality indicators’, and, ‘service delivery’. The systematic

bibliographic database searches where possible utilised MeSH medical subject headings. MeSH

provides descriptors in a hierarchical structure that permits searching at various levels of specificity.

The following MeSH subject headings were used; ‘service standards’, ‘workforce development’

‘Indigenous’ and ‘Aboriginal Health’. Subject terms of key words for the Google Scholar search

included combinations of the terms above. The terms were agreed prior to undertaking the integrative

review.

All search results were reviewed and relevant publications were imported and manually entered into an

Endnote bibliographic software program, broadly categorised into type of document and analysed in

relation to the topic and focus area. Given the broad nature of the search topic and the reliance on grey

literature to identify relevant documents the search continued as the review progressed.

Inclusion Criterion

Publications from 2004 to (March) 2014 were included in the review. The search included:

Original research papers

Peer reviewed opinion papers

Service or service standards evaluation reports

Policy documents

Regulatory documents

Australian and international documents were included in the review. As described previously, the

reference lists of published papers, policy documents and evaluation reports were also examined to

determine whether there were any additional resources which would be valuable to include.

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Findings

A total of 84 papers and documents were included in this integrative review. Relevant papers and

documents were reviewed and categorised in relation to the review framework into broad categories

that inform the framework:

1. Service provision for Aboriginal families

2. Service standards principles and content

3. Implementation and evaluation

4. Policy and/or regulation that inform standards/services

5. Workforce development

Review papers and documents were analysed and discussed under these broad headings.

A graphical representation of the literature search and review process is provided in Figure 2.

Figure 2: Literature Review process and papers

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The National Framework for Universal Child and Family Health Services

The National Framework for Universal Child and Family Health Services (The Framework) sets out a

vision for the provision of health services for all Australian children that states ‘All Australian children

benefit from quality universal child and family health services that support their optimal health and

development’ (13. p2.) . The Framework outlines service principles to achieve the vision and these

include access; equity; focus on promotion and prevention; partnership with families; recognising and

respecting diversity; collaboration and continuity; and evidence-based service provision. The service

principles identified in the Framework also appear alongside others as essential principles that should

underpin Aboriginal child and family health services (see Table 1.).

The evidence-based statement relates to both service provision and professional practice approaches.

The evidence-based service provision is evident in the service principles (above) and the practice-

based evidence is supported in the Framework through core service elements and performance

indicators. Table 2 outlines the core service elements that should be present in all child and family

health services (13. p3.).

Table 2: Core service elements section from the National Framework for Universal Child and Family Health Services

Core Service Elements

Developmental

surveillance and

health

monitoring

Monitoring physical, social and emotional and cognitive development

Physical health, growth monitoring, oral health

Vision and hearing assessment

Assessment of family psychosocial risk and protective factors

Health

Promotion

Prevention of disease, illness and injury

Health education and anticipatory guidance

Support for mothers, fathers and carers

Community capacity building

Early

identification of

family need

Identify the factors known to increase the likelihood of a child experiencing poorer health, development and wellbeing outcomes

Work with parents, families and communities to build strengths and address needs

Facilitate and coordinate, where appropriate, support across multiple services

Responding to

identified need

Information, advice and assistance

Brief practice-based interventions

Referral for further assessment and diagnosis

Referral or invitation for further support within universal health services

Referral for additions or enhanced targeted services

Respond appropriately to child protection concerns

Whilst universal services is the vision, consideration needs to be given to the historical and current

difficulties that some Aboriginal families continue to experience in accessing mainstream universal

services (14). There continues to be the need to provide Aboriginal specific services as a strategy to

support universal service provision (14)

Service provision for Aboriginal families

The papers and documents reviewed under the service provision for Aboriginal families predominantly

described necessary or favourable characteristics of service provision and service design. These

papers and documents have informed the development of evidence-based principles that should guide

the development of services for Aboriginal children and their families (see Figure 3.). In addition,

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included in this broad category were papers and documents that examined and/or evaluated specific

programs for Aboriginal families.

Despite efforts to ‘close the gap’ disparity remains between Aboriginal and non-Aboriginal Australians

in terms of Aboriginal disease burden and common health indicators and measures (15, 16). It is now

widely accepted that colonisation had, and continues to have, a negative impact on the health and

wellbeing of the First Nation Peoples in Australia (4). In recognition of this, colonisation is now well

accepted as a social determinant of Indigenous health (17). In an attempt to address the burden of

disease that exists for Aboriginal Peoples various interventions and strategies have been introduced

with varying rates of success.

The Commonwealth Department of Health aims to improve services for Aboriginal Peoples through

three targeted approaches to service delivery. Firstly, through improving access and responsiveness of

existing mainstream health services, then by providing Aboriginal specific services and lastly through

improving service delivery by increasing cross government collaboration (18). One aspect of this cross-

government collaboration is the National Partnership Agreements between the Commonwealth and

state and territory governments. These agreements ensure governments are working towards a

common framework, using common indicators and measures, and policies. There are six National

Partnership Agreements in relation to the Closing the Gap policy and the first of these is Indigenous

Early Childhood Development (8, 19).

Community development and Community-led design of services

Although many programs developed or applied to Aboriginal health claim to use a ‘community

development’ approach, in reality there is contention as to what this actually means and how it

translates into service provision (20). Much of the published evidence in regard to community

development describes the process but fails to measure or discuss the outcomes (20) This is not to

say that community development is not successful, but historically there has been a lack of evaluation

on the process and outcomes and as such, the process is not well represented in the literature (20).

Despite the lack of formal evaluation, there exists much report-based and anecdotal evidence of the

success of various community development programs and it continues to be an important underpinning

principle of service delivery in Aboriginal health.

Evidence from Australia and overseas demonstrates that for services to be accepted by those they are

designed for, a grass-roots approach is needed with community leadership and sustained involvement

in the development of the service. In Australia, the National Aboriginal Community Controlled Health

Organisation (NACCHO) claims that Aboriginal Community Controlled Health Organisations (ACCHO)

have been responsible for many of the health gains achieved in the past 50 years. NACCHO assert

that it is the grass-roots model of Aboriginal communities working with, and for, Aboriginal communities

that allows communities to reclaim control of health and self-determination (16). The NACCHO 10

Point Plan 2013-2023 lists key steps that they consider will support progress to closing the gap and

reaching health equality targets. These key steps include developing service models and workforce

strategies to build and sustain capacity and provide primary health care services where most needed

(16). In support of NACCHOs vision in relation to primary health care services for Aboriginal

communities the Australian Government has committed to working in partnership to improve delivery of

coordinated and culturally respectful care (18).

Despite widespread acceptance that programs developed for Aboriginal families should be led by, and

situated within Aboriginal communities, this is often not the case. Many programs designed and

delivered in mainstream child health are then ‘adapted’ for Aboriginal families. When programs are not

developed in respectful and inclusive ways, by involving the communities and families from the outset,

then often the programs are not suited to the needs of the communities (21). Aboriginal Peoples are

not a homogenous group and their cultures are complex and diverse. This diversity creates the need to

ensure any program developed has the flexibility to be adapted to the local context or Country where it

is to be offered (22).

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Specific programs for early childhood

Although the need for Aboriginal specific, early intervention, early childhood programs is widely

accepted there is limited rigorous research evaluating these programs (14, 23). In relation to

mainstream early childhood health services, there is extensive research to support provision of

accessible and appropriate universal services for all families (24) and much support exists around the

importance of ensuring best possible environments in the early years as these years have significant

impact on ensuring long-term health (23).

It is important to remember that much of the research into Aboriginal early childhood health services

has been conducted using western approaches to research and that Indigenous research

methodologies have not previously been widely utilised (25). In addition, much of the research into

early childhood health focuses on the physical aspect of health and largely ignores the social,

emotional and spiritual aspects of the child, the family and the community that they live in and to which

they belong. This approach disregards the whole of life view that is Aboriginal health and therefore

limits the research (4, 25-27). Historically, research into Aboriginal health has examined issues or gaps

and as such has taken a deficit approach to Aboriginal child health and fails to recognise and celebrate

the strength and resilience of individuals, families and communities (21). In an exploration of Australian

Aboriginal childrearing practices (5) Geia found that using a strengths-based approach shifts the focus

away from problems and focusses on community and family strengths. This and other research also

identified essential components required when preparing health practitioners to work in Aboriginal

communities. Essential components included community engagement, cultural respect and working in

partnership with communities (5, 27-31).

In a review of the literature regarding effective early intervention strategies for Indigenous children and

their families, Munro (14) set out to answer questions in regard to the provision of specifically designed

services for Aboriginal children and families and early intervention programs (with a focus on child

protection). The review investigated the effectiveness of these services, and if effective, what factors

may have contributed to positive outcomes. They found only one specifically designed program that

met the methodological selection criteria, the Aboriginal Maternal and Infant Health Strategy (AMIHS).

The other programs examined in the review were adapted from mainstream programs (14). The review

outlines three Australian programs that examined early intervention strategies and two of these used

the Positive Parenting Program (Triple P) as an intervention. One was a randomised clinical trial

testing the adaptation of the evidence-based Positive Parenting Program (Triple P) with Aboriginal

families. Results indicated that the response to the program was generally positive and the authors

claim that the results provide evidence that an effective program can be made to fit the needs of

Aboriginal people and can be delivered by Aboriginal Health Workers in a community setting (14). The

other two studies were mainstream programs with some Aboriginal families identified as participants.

A commonly identified effective strategy or underlying principle of early childhood health services for

Aboriginal children and families is the provision of a culturally competent service (14, 23, 30-33). Other

strategies include supporting equitable access through assistance with transport or providing an ‘in-

home’ service to negate the need for transport to access care; providing a flexible service delivery

mode; and, ensuring community consultation occurs at all levels of planning and service delivery (14).

Other characteristics in addition to program flexibility have been identified in the research regarding

successful prevention and early intervention programs for Indigenous children in the early childhood

years. In their review of the literature on health intervention programs for Australian Indigenous

children and families Bowes and Grace (21) present evidence around what works. This includes

programs that adopt a strengths-based approach; are family centred; involve communities in

development and implementation; adapt to suit local need so are therefore flexible; and, provide

integrative and collaborative services. In addition to these characteristics, the evidence supports

allowing longer lead in times to ensure appropriate and respectful engagement with communities and

high-quality cultural competence training for all non-Aboriginal staff (14, 21, 23).

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Specific programs for women during pregnancy and the first few weeks of life

Due to the lack of available published research literature on Indigenous specific early childhood health

programs a number of Indigenous specific maternal child health programs that are more pregnancy

and early weeks related are presented below.

A small number of specific services have been developed in Australia and Canada for Indigenous

women. In NSW, the goal of the NSW Aboriginal Maternal and Infant Health Service (AMIHS) is to

improve the health of Aboriginal mothers and babies. Midwives and Aboriginal Health Workers (AHWs)

or Aboriginal Health Education Officers (AHEOs) work together in small teams to provide a high quality

service that is culturally respectful, woman centred, based on primary health care principles and

provided in partnership with Aboriginal Peoples. AMIHS builds on the universal maternity services that

are available in NSW and has demonstrated improved outcomes for women and babies (34).

Evaluation of AMIHS programs demonstrated the following outcomes (34);

increase in the number of women accessing pregnancy care before 20 weeks gestation

decrease in the number of low-birth weight babies

decrease in the number of babies born prematurely

decrease in perinatal mortality

increase in initiation and continuation of breastfeeding, and

increase in rates of satisfaction for women accessing the service.

In addition to these results, an evaluation of an extended AMIHS program (including the provision of

labour and birth support) demonstrated a decrease in the rates of smoking and satisfaction with care

particularly in the areas of ease of access, having a known carer and being able to form trusting

relationships with caregivers (31, 35).

In northern Australia, the “Strong Mothers, Strong Babies, Strong Culture” Program (SMSBSC), was

developed in the 1990s as a community-based intervention program to address the discrepancy in

perinatal health outcomes for Aboriginal women in the Northern Territory. The intervention, involving

senior women in the Aboriginal communities aimed at helping younger women prepare for pregnancy,

support them during pregnancy by encouraging them to attend antenatal clinics early in their

pregnancy, and provide useful advice regarding healthy practices during pregnancy such as ceasing

alcohol consumption and smoking, maintaining a healthy diet including increasing “bush tucker” intake

and reinforcing the importance of seeking appropriate medical advice and adhering to treatment. An

evaluation of the program demonstrated a significant increase in birth weight of the babies of women in

the intervention group (36).

In Queensland, the “Mums and Babies” program is an integrated model of shared antenatal care

delivered by the Townsville Aboriginal and Islanders Health Service. An evaluation of the program

demonstrated a significant increase in the number of antenatal visits and the women were at an earlier

stage in their pregnancy at their first antenatal visit. Quality of antenatal care was improved and

perinatal outcomes improved in all areas, with a reduction in pre-term birth, and an increase in mean

birth-weight. Perinatal mortality was reduced from 60 per 1000 to 14 per 1000 (37).

Similarly, in the southern part of Australia, The Anangu Bibi Family Birthing program, staffed by

Aboriginal Maternal and Infant Care (AMIC) workers and midwives was established to provide care to

Aboriginal mothers and families in two sites in regional South Australia. Both the AMIC workers and the

midwives reported benefits from working together, the AMIC workers bringing the cultural knowledge to

the partnership and the midwives bringing the clinical knowledge. Whilst this study did not address

improved outcomes for mothers and babies, anecdotal evidence shows an increase in the use of

services by Aboriginal women and families (38).

In Victoria, the Women’s Business Service was implemented as a primary health care service. This

program provides holistic, personalised care by a midwife and an Aboriginal Maternal Health Worker

and was also evaluated favourably from the perspective of the women (39). Women who experience

care at the Woman’s Business Service were significantly more likely to feel positive about aspects of

their antenatal care such as feeling well informed, not feeling rushed and being happy with the care

NSW Health 14

than other women attending the rural public antenatal service. In addition, these women were

significantly more confident in caring for their babies and less likely to want additional help or advice in

their first week at home (39).

More recently in the Northern Territory, The Darwin Midwifery Group Practice (MGP) has been

established to provide continuity of care/carer for remote-dwelling Aboriginal women from seven Top

End remote communities, who travel to Darwin for birth (40, 41). A costs analysis of this model of

service provision for remote dwelling Aboriginal women who travelled to Darwin to give birth, showed

MGP was cost effective, and women received better care and experienced equivalent birth outcomes

compared with the baseline maternity care (40).

There are also international examples of primary health services for Indigenous women and families.

For example, the Inuulitsivik Midwifery Service and education program integrates both traditional and

modern approaches to care and education and has returned childbirth to the remote communities of

Nunavik, one of the Inuit regions of Quebec, Canada. This service provides care for seven

communities in the Hudson Bay and Hudson Straits areas with a population of around 5500. All the

communities are accessed by ‘fly-in’ and the tertiary referral centre is more than 1000 miles away in

Montreal. Previously, women were evacuated from their homes and flown to southern Canada four or

more weeks before the due date to give birth, and they stayed one or two weeks after the birth, thus

isolating them from their families for 5-8 weeks (42). The Inuulitsivik model provides midwifery-led

antenatal and postnatal care and birthing services for women of “low-risk” in the larger villages of the

Hudson Coast. The smaller villages receive onsite antenatal care but are transferred to give birth. This

comprises around 25% of the women in this area, however they are receiving antenatal care in their

own language, in their home region, by Inuit midwives (43). Evaluations of the model demonstrate

improvements in perinatal mortality, increase in birth weight, decrease in preterm birth and increase in

breastfeeding rates (44).

Review and analysis of literature related to service provision for Aboriginal families provides direction in

terms of characteristics or components required of such services. Evaluation of Aboriginal maternal,

child and family specific services for the purpose of this review has informed the development of

evidence-based principles that should be incorporated into existing services or used when developing

services for Aboriginal women and families. The evidenced based principles are listed in Table 3.

Table 3: Summary of the evidence in relation to service provision

Evidenced based principles that underpin Aboriginal child and family health programs

1. Ensure community leadership and sustained involvement in the development of the service 2. Consistent with the principles of Primary Health Care 3. Invest in capacity building for sustainability 4. Provide targeted funding for Aboriginal specific services 5. Provide locally accessible and appropriate services for all families 6. Provide a culturally competent service 7. Ensure flexibility in implementation and service delivery 8. Support a strengths-based and family centred approach 9. Provide integrated services 10. Promote high quality communication and collaboration

Whilst not made explicit in the service standards literature, there is an assumption that all care

provided by services for Aboriginal children, families and communities will be evidence based where

evidence is available and if evidence is lacking will be based on expert consensus.

Service Standard Principles

Relevant papers reviewed in regard to service standards or the principles that underpin service

standards included papers that defined or provided information on what a service standard is and what

they are commonly used for. Whilst a number of papers described or presented service standards

there was a dearth of information regarding the evaluation of or results from implementing service

standards.

NSW Health 15

Although evidence of health related service standards or service delivery standards have been present

in the literature from more than three decades ago (45), in the past ten years there has been a

significant increase in the number of service standards developed and produced. Since the advent and

acceptance of national and international health accreditation processes such as the WHO Health

Systems Performance Assessment Framework (WHO HSPA), the OECD Health Care Quality

Indicators Project (HCQI) and the Australian National Health Performance Framework (46, 47), the

development and subsequent use of service standards or service delivery standards has increased.

Service standards should be linked with national policies and best practice frameworks (48-52). In the

area of child and family health services and in particular services for Aboriginal children and families,

service standards should therefore be informed by:

Respecting the Difference An Aboriginal Cultural Training Framework for NSW Health

PD2011_069;

the National Framework for Universal Child and Family Health Services;

the Aboriginal and Torres Strait Islander Health Performance Framework; and

the proposed National Framework for Aboriginal and Torres Strait Islander Child and Family

Health Services (1, 13, 15, 23, 53, 54).

In relation to the BSF service standards, these will also be informed by relevant NSW state policies

and frameworks. The Standards will also be informed by the experiences and expertise of those

currently working within BSF services across the state.

Defining service standards

Health performance measurement systems and processes are becoming widely accepted and

increasingly important in health service provision across Australia (55). In particular, health

performance measurement in relation to Aboriginal and Torres Strait Islander health outcomes has

become more focussed since the introduction of the Aboriginal and Torres Strait Islander Health

Performance Framework (HPF) (56). Crucially, there are no clear, agreed definitions of a service

standard or quality indicator. At times, the literature uses these terms interchangeably. However,

agreement does exist that both should provide a target and a measure of services or care provided.

Despite all the interest in service standards, definitions or descriptions of what constitutes service

standards are lacking. Examination of the service standard literature provides limited information on

what service (delivery) standards are. The Department of Education and Children’s Services (49p.3)

state that service standards are:

‘…a set of clear and public criteria with explicit indicators that define the service delivery

performance by which Support Services can be monitored and reviewed.’

Furthermore, they go on to say that service standards are used to define the quality of service provided

by the organisation and therefore should be at a level that is clear, measurable and achievable (49p.3).

Similarly, the Institute for Citizen Services state that service standards:

‘…outline the specific delivery targets established by an organization [sic], and are made up of

a set of commitments that an organization [sic] promises to honour when delivering a service.’

While the stated definitions of service standards are similar and succinct, many of the reviewed

standards provided further detail when justifying the use or the purpose of service standards.

Justifying the use of service standards

There is a range of reasons given to justify the use of service standards in health care service delivery.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) developed standards to

introduce safety and quality systems to ensure high levels of health care provision (48). The

ACSQHC’s primary and overarching standard from the National Safety and Quality Health Service

Standards document concerns governance. The ACSQHC assert that Standard 1 provides a safety

and quality governance framework and informs all other ACSQHC standards. The governance

NSW Health 16

framework is designed to create a health system where performance can be monitored and continually

improved (48).

Provision of a system to monitor and improve service delivery and service quality is a common

justification for, or stated purpose of, service standards. Swersey (57), when discussing the use of

standards in health care, asserts that quality cannot be improved if it is not being measured. The

Queensland Government, in their Standards for Community Services state that setting service

standards is important to ensure community service provision is safe and able to be continuously

improved (58). The Victorian Government’s Human Service Standards were, in part, produced to try to

reduce ‘red tape’ so as to streamline monitoring and evaluation processes (59).

Whilst the majority of producers of service standards include quality improvement and monitoring

processes as a justification for the need for standards, there is some confusion regarding the

terminology used. There exists an undeniable relationship between service standards and quality

standards with the terminology being used interchangeably in some of the literature (48, 49, 59). In

addition, many of the standards reviewed included quality and/or performance indicators within their

respective frameworks.

Each service standards document reviewed uses some form of quality provision or measuring in

discussions around the purpose of the standards, but provision of quality or measures of quality is not

the sole purpose of standards. Another justification for the production and the increasingly widespread

use of service standards is the identification of evidence to support best practice. When the reviewed

standards documents provide information on the development of the standards, best practice and

evidence-based framework claims feature regularly (50, 60). Given the focus on high quality service

provision and quality care service, standards must be based on best practice care (50).

Further justification for the use of service standards is the expectation that there should be

standardisation or consistency in service provision or delivery so that each client or service user

experiences the same high level of quality care (48, 51, 61). Inconsistencies in service delivery may

affect the organisation’s ability to meet expected standards (best practice) in care provision. Many

services are underpinned by a vision, mission and/or guiding principles and inconsistencies in services

will impact on the organisation’s ability to ensure these are met. The service standards reviewed for the

purpose of this review covered a variety of services such as disability and juvenile justice services,

therefore each set of standards should include service specific information and service standards

developed for Aboriginal child health services will contain information on child health development and

wellbeing outcomes and cultural care.

Structure of service standards

Although the structure of the reviewed service standards differs, essentially the content of the

standards is similar. Many standards documents have a small number (4-12) of overarching ‘standard’

statements and within each standard there are elements/components/outcomes and performance

criteria, evidence or measures (48, 50, 59, 60, 62, 63). Alternate structures include statement of a

standard and explanation points with practice tips and the provision of a separate tool for auditing or

measuring (61, 64). The Community Relations Commission for a Multicultural NSW used an alternate

approach in format whereby they identified three activity areas. Each activity area is comprised of

outcomes, which when compared with similar service standards or service standard frameworks, the

outcomes could be identified as service standards (52).

Regardless of the differing structure and nomenclature used in standards documents, most of the

standards provide information on the development process. This includes advocacy for a systematic

approach to development that includes defining quality services, stakeholder engagement,

development of quality indicators and a plan for implementation (45, 48, 49, 57, 60, 65). Swersey (57)

proposes a detailed development framework that includes determining the needs of customers;

defining what quality is and developing a quality statement; measuring satisfaction; being specific

about the expected standards of service; and, developing key quality measures.

NSW Health 17

The Department of Education and Children’s Services (49) provide further detail on a framework for

development that includes additional considerations such as consideration of existing policies or

standards and consideration of the roles and responsibilities of staff within the services. Others

advocate the creation of a mission statement to provide clarity (51) comprehensive consultation and

consensus (66) and, ensuring standards are developed within an evidence-based best practice model

of service provision (48, 50, 60, 62, 67, 68).

Regardless of the process for development of service frameworks or standards identified, broad key

components for best practice service provision include an effective evaluation process and assessment

of hard to produce proof of the effectiveness of the program. In relation to maternal, child and family

health, programs must also be based on strong evidence and supported by accepted theories of

child/family health and development. It is also recommended that programs be replicable in that a

program is able to be implemented and provide consistent outcomes in varying locations and this is

only possible when the program has identified core components, values and service delivery models or

service standards. Other key components are that programs are innovative and have cultural reach

and are culturally competent (69).

Table 4: Matrix of key features or principles presented in Service Standards documents

Service Standard Document Title

Key features or principles presented as standards (shaded indicates present)

Relationship/

Partnerships

Participation Acces

s

Communication

/Collaboration

Cultural

relevance

Wellbeing System

processes (HR,

complaints)

Organisational

Management

Workforce/

Recruitment

Support Services Service Delivery

Standards (Dept. of Education and

Children’s Services South Australia)

(49)

Standards Evidence Guide

(Department of Human Services Victoria)

(59)

Guide to the National Quality

Standard (Australian Children's

Education & Care Quality Authority)

(60)

Maternal and Child Health Service

Program Standards (Department of

Education and Early Childhood

Development Victoria)

(50)

Service Delivery Standards:

Indigenous Justice Program (Attorney

General's Department)

(62)

National Standards for Disability

Services (New South Wales

Government Family and Community

Services)

(66)

Standards for Community Services

(Queensland Government)

(58)

Community Care Common

Standards (Australian Government

Department of Health and Aging)

(63)

Building Blocks: Best practice

programs that improve the wellbeing

of children and young people -

Edition One (Commissioner for Children

and Young People Western

Australia)(69)

NSW Health 20

Other ways of describing key elements within standards

In addition to the standards identified in this systematic review, the search identified further literature

that related to service standard content but were not actual service standards. Again, due to a lack of

published literature specifically addressing Aboriginal early childhood health services the following

information is based on maternal and early weeks programs. A rapid review of the literature in relation

to maternity service requirements for Indigenous mothers and babies in Australia, Canada, New

Zealand and the United States of America by Kildea and Van Wagner (32) identified the key service

elements that could translate into service standards in a broad sense. The elements are:

governance and ownership;

having an identified philosophy and service characteristics;

provision of appropriate training and education; and,

monitoring and evaluation mechanisms.

The consultation paper on the proposed National Framework for Aboriginal and Torres Strait Islander

Child and Family Health Services (53) also includes key elements that services should incorporate and

these include:

being culturally competent and safe;

understanding and responding to community and population needs;

maximising service access; and,

collaboration, coordination and integration with relevant services.

This consultation paper relates specifically to Aboriginal and Torres Strait Islander child and family

health service provision and as such the suggested key elements should be utilised in both the

development of service standards and the provision of services for Aboriginal and Torres Strait Islander

families.

Developing and measuring service standards

Limited information is available for a best practice model in regard to developing service standards.

Swersey (57) advocates for a structured approach that involves defining quality, stakeholder

engagement, having specific standards that have indicators or measures. Other development

processes advocate a similar approach but include using a systematic approach and basing the

standards on current best practice (48, 51). The majority of service standards documents identify the

importance of being able to measure against the standards.

The NSW Disability Service Standards provide and recommend the use of key performance indicators

(KPI) drawn from the standards and have developed a KPI guidance document to support the service

standards (64). Using the KPIs is encouraged and it is claimed that this will assist organisations in

evaluating activities and outcomes. In addition, it is suggested that measuring activity against the KPIs

will allow organisations to identify service improvement opportunities (64). Other measures advocated

in the literature include the development of evidence-based quality indicators so that benchmarking of

services can occur (70). Stelfox and Straus (70) provide a framework for developing quality indicators

that is similar to frameworks for developing service standards. The framework suggests that quality

indicators should be important to the audience, scientifically sound, feasible and usable. They advocate

a consensus approach to the development of these indicators.

Policy and Regulation

Development and implementation of appropriate and workable service standards must incorporate

relevant policy and regulatory requirements. Policies that are applicable to the BSF service standards

development include the following three broad areas:

NSW Health 21

1. Maternal, child and family health

2. Aboriginal and Torres Strait Islander health

3. Community development to improve child health development and wellbeing.

Five main documents provided insight into policy and regulation areas with respect to service

standards. These included policy frameworks and targets. Policy is however referred to in many other

areas in a more general sense.

Policy frameworks

A national review of state and territory maternal and child health policies identified differences in policy

frameworks across jurisdictions in Australia (33). Although informed by national policies, each state and

territory have developed and refer to separate policy frameworks. Fortunately commonalities include

alignment with international research and policy directions; a focus on prevention and early

intervention; emphasis on continuity of care and collaboration; and, integrating of services (33). The

review also identified the inclusion of distinct statements in regard to the importance of delivering

culturally appropriate services for Aboriginal and Torres Strait Islander children and families and this

included the promotion of linkages with Aboriginal Community Controlled Health Organisations (33).

Setting targets in policy

The National Aboriginal Community Controlled Health Organisation (NACCHO) in their 10-point plan to

achieve a healthy future for generational change, advocate for governments and policy makers to adopt

the targets and actions in the 10-point plan. The Healthy Futures 2013-2030 10-Point Plan states that

healthy futures and generational change will be achieved through investing in the Aboriginal

Community Controlled health sector so that innovative models of primary health care can be delivered.

This will be driven by Aboriginal health leaders and partnerships with other health services, and also

through health system reform. These actions will be underpinned by appropriate health financing, well-

prepared health workforce, strong health infrastructure, rigorous research and data collection and

processes that are accountable and report, monitor and evaluate services (16).

Policy supporting child and family health in NSW

In NSW, there are a number of policies that support both the provision of child and family health and

the provision of health services for Aboriginal and Torres Strait Islander families. The NSW Aboriginal

Health Plan’s strategic directions are particularly important when considering service standards and

service provision. The strategic directions (71) are:

1. Building trust through partnerships

2. Implementing what works and building the evidence

3. Ensuring integrated planning and service delivery

4. Strengthening the Aboriginal workforce

5. Providing culturally safe work environments and health services

6. Strengthening performance monitoring, management and accountability.

In addition, the New South Wales Government Plan NSW 2021 includes a child wellbeing section that

primarily focuses on prevention and early intervention for child health services.

The NSW Government’s policy suite Supporting Families Early package includes policy in regard to the

provision of maternal and child primary health care services and the Safe Start strategic policy with a

focus on coordinated services for families with psychosocial risk likely to impact on their parenting. The

Supporting Families Early package also provides overarching strategies for service provision similar to

the NSW Aboriginal Health Plan in that they highlight planning and partnership, ensuring a skilled and

supported workforce and implementation as key strategies to ensure appropriate service provision (72).

NSW Health 22

Developing a fit-for-purpose workforce

A number of documents and reviews were examined to determine the most effective factors that

contribute to developing a fit-for-purpose workforce in relation to the provision of child and family health

services for Aboriginal children and their families; and, the most effective human resources processes

to support, develop and assess individual and team performance against service standards.

Developing, supporting and sustaining a fit-for-purpose workforce are integral to the effective delivery

of the BSF programs and therefore the standards must acknowledge and incorporate workforce

development (73).

Influences on the workforce

Patient (or more relevant in this context communities, families, children), practitioner (nurse, Aboriginal

Health Worker, doctor, allied health ), and institutional outcomes are affected by current work

environments (74). Work environment includes staffing, leadership and management, commitment to

professional development and quality care, and relationships between staff members (75). There is a

well-established link between satisfied nurses, satisfied patients, and better quality of care and the

work environment affects satisfaction and turnover, that is, the propensity to leave the workforce or

workplace (76-78). Turnover is expensive as recruitment and replacement is costly, as is up-skilling

and orientation of new staff and high turnover is related to burnout, poorer mental health outcomes and

an increased likelihood of medical error (79-82). Therefore, attracting and keeping the health workforce

is important, no matter what the specific context area.

A health workforce that can deliver culturally safe services

Cultural competence is a critical component of a fit-for-purpose workforce and high quality cultural

competence training is required (21, 54). Cultural competence is defined as having the capacity to work

effectively with people from diverse backgrounds and being respectful while also recognising how the

individual’s culture influences the care given or received (14) .

It is essential that non-Aboriginal health professionals are supported in gaining an understanding of

Aboriginal ‘women’s business’ (83). The NSW Aboriginal Health Plan 2013-2023 (3) highlights the need

to develop structures, policies and processes required for culturally safe work environments. Aboriginal

people continue to experience institutional and interpersonal racism and this is relevant for both staff

and clients.

Health Workforce Australia (HWA) (84) is developing a curriculum framework as a necessary step in

creating a health workforce better able to respond to the needs of Aboriginal and Torres Strait Islander

peoples and communities and deliver culturally safe services. This national Aboriginal and Torres Strait

Islander health curriculum framework was developed in recognition of a lack of culturally competent

skills across all health professions and that Aboriginal and Torres Strait Islander Peoples are more

likely to access care when there is respectful communication and understanding or acknowledgement

of culture. It is hoped that this curriculum framework will play an important role in the future in ensuring

that pre-registration education of professionals, including nurses, midwives and doctors, and will

develop a workforce that can more readily deliver culturally safe and respectful services from the

outset. As a result of the 2014-2015 Federal Government budget announcement Health Workforce

Australia’s program functions are to be transferred to the Commonwealth Department, Health

Workforce Division. Health Workforce Australia have informed all stakeholders that the Implementing

an Aboriginal and Torres Strait Islander Health Curriculum Project with the Curtin University project

team will continue until the end of the project with accountability to the Commonwealth Department,

Health Workforce Division (Personal Communication).

In addition to the proposed introduction of the HWA curriculum project, there are a number of other

resources available to assist in developing a culturally respectful and competent workforce. All New

South Wales Health employees are mandated to complete both online and face-to-face cultural respect

training through the completion of the cultural training framework Respecting the Difference (54).

NSW Health 23

A structured literature review on early childhood interventions for Indigenous families identified that

workforce development in Indigenous health programs must incorporate employment and building

capacity of local Indigenous people (21). This requires community leadership and endorsement and a

commitment to being strengths-based, not only for the clients but also for the workforce. An effective

workforce, whether Aboriginal or Non-Aboriginal, needs to depend on trust and relationship building.

Non-Aboriginal staff need particular attention to being the ‘right kind of person’, that is, being able to

work effectively in a cross-cultural, flexible and collaborative manner. Training and supportive

supervision needs to be built into a workforce development strategy to ensure that staff with these

qualities are recruited into the programs (21). A review undertaken to develop the framework for

Universal Child Health Services highlighted that attention is needed in initial and ongoing training,

cultural competencies, staff support and mentoring (13).

Capacity building of the workforce

Capacity building has been identified in a number of policy documents as being critical to the

development of the workforce, especially, the support of Aboriginal and Torres Strait Islander peoples.

In NSW, the Aboriginal Health Plan 2013-2023 (3) focuses on developing and nurturing the Aboriginal

health workforce, in particular the unique role of the AHW. The Plan includes a number of strategies to

improve recruitment, retention, education and training. These include Aboriginal health cadetships for

student nurses and midwives which are currently being evaluated.

Building capacity of an Aboriginal health workforce is one of the key outcomes of the Aboriginal

Workforce Strategic Framework. The key outcomes include increasing the Aboriginal workforce to 2.6%

of the health workforce by end 2015; having targeted positions and specifically designed recruitment

and retention processes; provision of strong leadership; supported access to continuing professional

development opportunities; strengthen Aboriginal workforce data collection; and, ensuring all NSW

Health staff complete the mandated Aboriginal Cultural Training (73).

In addition to strengthening and building capacity in the Aboriginal workforce, it is important to consider

actively building the capacity of non-Aboriginal staff who work in Aboriginal health. In part, this is

supported in the BSF programs by ensuring all Child and Family Health Nurses work in partnership with

Aboriginal Health Workers when working with families and in communities. As discussed previously this

also should include recruitment of the ‘right’ person for the position and ensure adequate mentorship

and training is available so staff can deliver culturally respectful, flexible and collaborative care (21). It

is believed that supporting all staff to improve understanding and develop respect for Aboriginal people,

families and communities will enable staff to form meaningful and respectful professional relationships

which in turn will improve health outcomes (54).

Clarity of roles, responsibilities and competencies

Clarity about the roles, responsibilities and competencies is required to ensure that services can

function efficiently and effectively (31, 85). This clarity will inform workforce and recruitment and

continuing professional development (85, 86).

According to the NSW Health Child and Family Health Nursing Professional Practice Framework 2011-

2016 a Child and Family Health Nurse (CFHN) works within a primary health care model in a variety of

settings and the foundation of their practice is working in partnership with parents (87). In addition to

documenting core skills and knowledge required for the profession the CFHN also define their scope of

practice under three areas of practice;

1. Infant child health surveillance and screening

2. Family assessment and surveillance for emotional health and wellbeing

3. Infant, child and family care

Child and Family Health Nurses’ practice is guided by the ANMC Competency Framework for

Registered Nurses and NSW CFHN Professional Practice Framework.

NSW Health 24

The Aboriginal Health Worker’s practice, in NSW is guided by the Definition of an Aboriginal Health

Worker Information Bulletin (88). There is recognition that there has been inconsistency in the definition

and understanding of the role of Aboriginal Health Workers both in NSW and nationally. Changes in

national regulation in regard to the advent of the Aboriginal and Torres Strait Islander Health

Practitioner Board of Australia and new National Skills Council qualification standards for Aboriginal

Health Workers has supported the need for clarity in defining the role and scope of practice of

Aboriginal Health Workers (89, 90). Although there is recognition of role diversity the following

characteristics were universally present in all Aboriginal Health Workers (91);

Aboriginal primary health care provision

Cultural security and safety

Health promotion

Local Community knowledge

Holistic health care approach

The recognition of an equal partnership between Aboriginal Health Workers and Child and Family

Health Nurses and respect for the skills, knowledge and attributes each partner brings to their role is

vital to ensure the BSF programs provide safe and effective care to Aboriginal children, families and

communities.

Clarity about roles and responsibilities assists effective team building which was critical to the success

of the AMIHS programs (85). This is also important for job satisfaction and retention. Workforce

strategies identified in relation to the AMIHS programs, especially to support retention, included;

adequate orientation to the program and the community

prompt and effective conflict resolution if this is required

effective management and leadership with clear lines of accountability, performance

management, clinical supervision and support for education and training

clear strategic direction

respectful relationships within the team, and

occupational autonomy and flexibility.

Conclusion

This integrative literature review will inform the development of the BSF Standards and workforce

strategy documents. The review has highlighted key components and principles that should be present

in service delivery and development of service standards for Aboriginal specific child and family health

programs. Service standards must be supported by policy direction and regulation and informed by

evidence and best practice principles.

Workforce development strategies and capacity building must ensure that those who work in programs

that provide services for Aboriginal children, families and communities can demonstrate cultural

competence relevant to the community they work with. Training and supervision needs to be provided

on an ongoing basis and those working in the programs benefit from high levels of occupational

autonomy and flexible work practices and service delivery.

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