Strategies to optimise culturally appropriate perioperative care for Strategies to optimise culturally appropriate perioperative care for Aboriginal and Torres Strait Islander peoples: A discussion paper Aboriginal and Torres Strait Islander peoples: A discussion paper

paper Abstract The disparity in health outcomes between Indigenous and non-indigenous Australians continues to increase. Barriers to accessing health care, particularly surgical treatment, contribute to health inequalities among Indigenous Australians. Despite a positive correlation between improved patient experiences and health outcomes, there is little research available on nursing interventions to improve Indigenous patients’ perioperative health care treatment. This discussion paper investigates culturally appropriate and evidence-based nursing interventions that can be applied in the perioperative setting to improve the surgical experience of Indigenous patients. It was shown that establishing trust among Aboriginal and Torres Strait Islander patients through anaesthetic nurse practices and advocating for family involvement is critical in providing culturally safe care and enhancing patient experiences. Indigenous health liaison officers were also identified as a valuable resource in bridging cultural and communication gaps between health care providers and Indigenous patients. These findings demonstrate that using tailored nursing strategies while providing perioperative care to Indigenous Australians can enhance their perioperative health care experience and contribute to improving health outcomes of Indigenous Australians. It is therefore recommended that perioperative nurses adopt these strategies; however, further research is needed to investigate implementation of an enhanced role for anaesthetic nurses, advocating for family involvement and referral to Indigenous health liaison officers. Such research should evaluate the impact of these new holistic and patient-centred approaches on the health outcomes and experiencecs of Indigenous patients.

Strategies to optimise culturally appropriate perioperative care for Aboriginal and Torres Strait Islander peoples: A discussion paper Abstract The disparity in health outcomes between Indigenous and non-indigenous Australians continues to increase. Barriers to accessing health care, particularly surgical treatment, contribute to health inequalities among Indigenous Australians. Despite a positive correlation between improved patient experiences and health outcomes, there is little research available on nursing interventions to improve Indigenous patients' perioperative health care treatment.
This discussion paper investigates culturally appropriate and evidencebased nursing interventions that can be applied in the perioperative setting to improve the surgical experience of Indigenous patients. It was shown that establishing trust among Aboriginal and Torres Strait Islander patients through anaesthetic nurse practices and advocating for family involvement is critical in providing culturally safe care and enhancing patient experiences. Indigenous health liaison officers were also identified as a valuable resource in bridging cultural and communication gaps between health care providers and Indigenous patients. These findings demonstrate that using tailored nursing strategies while providing perioperative care to Indigenous Australians can enhance their perioperative health care experience and contribute to improving health outcomes of Indigenous Australians.

Introduction
Indigenous Australians continue to experience poorer health outcomes than non-Indigenous Australians, despite decades of government initiatives aimed at closing this gap. [1][2][3] Continued barriers to accessing specialised care, such as surgery, contributes to disease progression, causing patients to present at later stages of illness which, in turn, leads to increased rates of post-operative complications, morbidity and mortality. 4,5 According to Jones et al. 6 some of these barriers include a lack of culturally appropriate care and previous negative health care experiences.
As health care decision-making often involves family and community participation, community members' shared health care experiences can influence Aboriginal and Torres Strait Islander people's decisions to seek health care. 6,7 In order to facilitate a positive surgical and health care experience, perioperative nurses must provide high-quality and culturally appropriate care. By doing so, positive health care experiences may be disseminated throughout Indigenous families and communities, therefore encouraging others to seek health care and ultimately contribute to improved health outcomes. 6 This discussion paper aims to highlight two key perioperative nursing strategies to optimise the perioperative care and experiences of Aboriginal and Torres Strait Islander people.

Discussion
Extensive reading of literature until saturation had occurred, allowed for thematical analysis, critique and evaluation, and synthesis of the relevant literature. This discussion paper presents five themes: 'background to the problem', 'current perioperative practice', 'building trust with Aboriginal and Torres Strait Islander patients', 'the anaesthetic nurse as a trust builder' and 'advocating for Indigenous health liaison officers'.
The discussion will highlight two key perioperative nursing strategies to optimise the perioperative care and experiences of Aboriginal and Torres Strait Islander patients -the nurse's role in advocating for Indigenous health liaison officers (IHLOs) in the perioperative setting and building trust between the patient and clinicians. The impact of these strategies and the barriers to their use will be explored.

Background to the problem
Indigenous Australians' spiritual, social, mental and physical wellbeing continues to be adversely affected by the historical and intergenerational trauma caused by British colonisation. 8 Longterm health implications include mistrust of health care systems, unwillingness to seek treatment, burden of disease and poorer health outcomes. 8 Despite Australia being a wealthy and developed nation, the life expectancy of Indigenous Australians remains comparable to underdeveloped nations. 8,9 Government programmes and initiatives, such as the 'Close the gap' campaign, have been ineffective in addressing these disparities, emphasising the need for an immediate transformation. [1][2][3] Indigenous Australians are further disadvantaged in the perioperative context due to surgical disparities such as inequitable timely access to surgical services, difficulty building patient-clinician trust, and lack of culturally appropriate services. 5,10,11 In a systematic review of Aboriginal and Torres Strait Islander people's health care experiences, Jones et al. 6 highlighted that improving patient experiences can lead to improved patient outcomes. Therefore, perioperative nurses should adopt strategies that optimise patient experiences in the perioperative setting in order to improve culturally safe patient care.

Current perioperative practice
Although the Nursing and Midwifery Board of Australia (NMBA) mandates cultural safety training, the techniques and tools for providing culturally safe care are generalised across all areas of nursing. 12,13 A scoping review of nursing initiatives to enhance cultural safety and the perioperative experiences of Indigenous Australians yielded limited findings. Significant gaps in the literature demonstrate the need for immediate action at both national and local levels, beginning with perioperative nursing care at the forefront of optimising patient experience. Perioperative care is extremely valuable and contributes to improved quality of life for Australians. [14][15][16] As perioperative nursing is a vast and well-resourced specialty, perioperative nurses have the power to make meaningful changes to ensure that Indigenous Australians have equal access and receive culturally appropriate care while undergoing surgery. 6,14,17 Building trust with Aboriginal and Torres Strait Islander patients The significance of establishing trust was one of the most prevalent themes that emerged from a review of the available literature. [4][5][6]18,19 Trust, according to Ozaras and Abaan, 20 is defined as believing in each other without fear or hesitation and interacting with compassion that develops over time. Trust has two dimensions: institutional trust at the government level and interpersonal trust at the professional level. 20 Many Indigenous Australians have inherent mistrust in government services in both these aspects of trust, leading to an unwillingness to access health care which results in a continuous cycle of poor health outcomes. 6,8 In a qualitative study conducted by Nolan-Isles et al., 8 interviews (n=31) with Indigenous Australians in remote communities were used to identify enablers to accessing health care services. Trust in the service provider and the experience of cultural safety emerged as a major finding. 8 These findings highlight the value of establishing trust between nurses and their patients in order to enhance the surgical care experience for Indigenous Australians.

The anaesthetic nurse as a trust builder
A strategy for building trust with Aboriginal and Torres Strait Islander patients in perioperative care is to have the same health practitioner interact with the patient at all stages of the perioperative journey. 6,7 The anaesthetic nurse may be ideal for this role as they are typically the first health professional to greet the patient in the operating suite, they spend the most time with the patient while the patient is awake, and they are often the last person the patient sees before being anaesthetised. 21 When performing the pre-operative safety checklists, the anaesthetic nurse should communicate with cultural sensitivity and respect which, in turn, will allow the patient to ask questions and feel more comfortable, welcomed and safe. 6,8,16 This approach is supported by Jones et al. 6 who conducted a systematic review of 54 studies on Indigenous Australians' experiences in health care and stated that establishing trust was one of the three most important factors in improving the health care experience. Twelve of the publications analysed by Jones et al. indicated that spending more time with patients allowed for the development of stronger and more trusting relationships. 6 Although this review was of high quality and met PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria, it should be noted that this research did not specifically focus on perioperative care, with only one paper investigating the operating suite environment.
While it has been suggested that constraints due to fast turnover of operating lists may not allow enough time to build trust, the anaesthetic nurse may still be an ideal health professional for this role as they are considered to be 'the patient advocate'. Thus, they are tasked to care for and speak up for their patients, 22 which is especially important for the more vulnerable populations, such as Aboriginal and Torres Strait Islander patients. 12,23 Another strategy the anaesthetic nurse could use to build trust among Indigenous patients is, when appropriate, to advocate for family presence in the operating theatre. Ristevski et al. 24 and Wotherspoon and Williams 25 report positive effects on health outcomes associated with family involvement, as well as the personal and cultural importance of family presence when receiving care. When a family member is present, Indigenous patients are more likely to feel culturally safe and empowered to make decisions, which improves trust and the quality of care. 6,24,25 This practice is supported by the Australian College of Perioperative Nurses (ACORN). The ACORN standard, Visitors to the perioperative environment, states 'Patients with special needs or requirements shall have a patient support person to accompany them in the perioperative environment.
[The support person] cares for the unique needs of the patient e.g. effective communication on behalf of the patient with unique psychological or spiritual requirements'. 26, p335 Further, Nolan-Isles et al. 8 report that having a trusted family member present can provide additional information, explanation or support to Indigenous patients, as well as break down any communication barriers between the patient and health care professionals. While this qualitative study emphasises the importance of family presence while receiving health care, the interviewed sample size (n=31) only reflects the perspectives of a limited number of individuals and therefore cannot be generalised to all Indigenous Australians. 8 Consideration should also be given to the possibility that Indigenous patients might not want family members present owing to cultural beliefs, privacy, confidentiality or personal preference. 8 The evidence demonstrates that building trust through the implementation of these strategies will mean patients are more likely to engage in health care in the future and share their experiences with family and community, therefore removing a barrier to Indigenous people seeking surgical treatment.

Advocating for Indigenous health liaison officers (IHLOs)
IHLOs are Aboriginal and/or Torres Strait Islander health care workers who collaborate with Indigenous patients to achieve better access to health care, bridge communication gaps, provide emotional support and advocacy, and assist with social services. 27 According to Mackean et al., 27 IHLOs are crucial for closing the gap in health outcomes; and Jones et al. 8 concur, adding that IHLOs help move the power dynamic back towards the patient and re-establish their identity and status as clients within the health care system. IHLOs are accessible in most hospital specialities, but not usually in the perioperative setting or pathway to surgery. 27,28 Aboriginal and Torres Strait Islander people tend to nod or say 'yes' even when they do not understand what is being said, either out of respect for health care professionals or because the patient is too intimidated to ask questions. 29 This sense of disempowerment is exacerbated when engaging with health care professionals in positions of power or multiple health care professionals, such as in surgical clinics or operating theatres, and raises concerns about obtaining informed consent. 30 It is therefore suggested that surgical clinic nurses and perioperative nurses ask the question, 'Would you like an IHLO to provide support to you and your family?' When IHLOs are used in surgical clinics, they provide the opportunity to empower patients to ask questions, clarify any medical jargon, facilitate an informed consenting process and work with individuals, families and social services to facilitate travel and accommodation during perioperative care. 28,29 The perioperative nurse should also advocate for using an IHLO for Indigenous patients requiring emergency surgery. 22,23 While there is little data on IHLOs being used in perioperative care, Topp et al. 28 argue the importance of IHLOs in emergency situations. Topp et al. 28 interviewed IHLOs and Indigenous and non-Indigenous community members (n=83) to determine the distinctive skills, scope and value of IHLOs. It was discovered that IHLOs within emergency departments are crucial in translating language and explaining situations at a level that patients and families understand. 28 Although this study was limited to emergency departments, the findings are also applicable to emergency surgery as IHLOs would perform the same role in providing patient and family support and can assist in the informed consenting process. Furthermore, effective information exchange is crucial in surgical settings 4 where Indigenous patients are more likely to feel powerless, intimidated and confused by medical terminology. 29 IHLO involvement in these situations is integral to bridging any cultural and communication gaps between patients and health care professionals. 28 Therefore, the simple nursing intervention of offering IHLO assistance in surgical clinics or in perioperative settings can give Indigenous patients a better surgical experience and contribute to safe outcomes. 27,28 Barriers to establishing a perioperative IHLO include the expenses related to employing personnel, difficulties recruiting qualified staff and the possibility that IHLOs might not be available to provide a 24/7 service. 30 Additionally, not all Indigenous patients accept IHLO support, particularly in smaller communities where there may be concerns about privacy and confidentiality. 8 To address these barriers, drawing on existing IHLOs in surgical wards or emergency departments is proposed when clinic and perioperative IHLO assistance is required.

Conclusion
This discussion paper has illustrated the existing gaps in nursing literature and clinical practice regarding culturally appropriate perioperative care of Aboriginal and Torres Strait Islander patients. The discussion presents unique strategies to build trust and improve the health care experience and health outcomes of Indigenous Australians. The innovative nursing strategy of fostering IHLO involvement in surgical clinics and the perioperative setting may enhance culturally appropriate care and improve perioperative experiences.
Developing strong and trusting nurse-patient relationships with Indigenous patients in the perioperative environment is one of the most effective ways nurses can provide culturally safe care and contribute to closing the gap in health outcomes. Trust-building strategies include having the anaesthetic nurse interact with the patient throughout the perioperative journey, tailoring care to the individual needs of each patient and informing them of the option to have a family member and/or IHLO present in the perioperative unit. Indigenous Australians' perioperative experience can also be improved by outsourcing IHLOs to surgical clinics and operating theatres. Adopting these strategies to improve the health care experience of Indigenous Australians can potentially encourage families and communities to access health care, ultimately contributing to the improvement of Aboriginal and Torres Strait Islander people's health and wellbeing.
It is recommended that further research be conducted specifically into Aboriginal and Torres Strait Islander people's experiences in perioperative care and, when introduced, how the discussed strategies have impacted patient experiences and health outcomes.
While trust-building strategies, family involvement and IHLO involvement have not been well utilised in perioperative practice, the positive lessons from other health care environments are evident, providing impetus to trial such interventions in perioperative practice. The ability to improve the quality of Aboriginal and Torres Strait Islander patients surgical journey relies on such change.