title: Hospitals caring for rural Aboriginal patients: holding response and denial.
abstract: OBJECTIVE
  To investigate how policy requiring cultural respect and attention to health equity is implemented in the care of rural and remote Aboriginal people in city hospitals.
  
  
  METHODS
  Interviews with 26 staff in public hospitals in Adelaide, South Australia, were analysed (using a framework based on cultural competence) to identify their perceptions of the enabling strategies and systemic barriers against the implementation of official policy in the care of rural Aboriginal patients.
  
  
  RESULTS
  The major underlying barriers were lack of knowledge and skills among staff generally, and the persistent use of 'business as usual' approaches in their hospitals, despite the clear need for proactive responses to the complex care journeys these patients undertake. Staff reported a sense that while they are required to provide responsive care, care systems often fail to authorise or guide necessary action to enable equitable care.
  
  
  CONCLUSIONS
  Staff caring for rural Aboriginal patients are required to respond to complex particular needs in the absence of effective authorisation. We suggest that systemic misinterpretation of the principle of equal treatment is an important barrier against the development of culturally competent organisations. WHAT IS KNOWN ABOUT THIS TOPIC?: The care received by Aboriginal patients is less effective than it is for the population generally, and access to care is poorer. Those in rural and remote settings experience both severe access barriers and predictable complexity in their patient care journeys. This situation persists despite high-level policies that require tailored responses to the particular needs of Aboriginal people. WHAT DOES THIS PAPER ADD?: Staff who care for these patients develop skills and modify care delivery to respond to their particular needs, but they do so in the absence of systematic policies, procedures and programs that would 'build in' or authorise the required responsiveness. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: Systematic attention, at hospital and clinical unit level, to operationalising high policy goals is needed. The framework of cultural competence offers relevant guidance for efforts (at system, organisation and care delivery levels) to improve care, but requires organisations to address misinterpretation of the principle of equal treatment.
authors.affiliation: Department of Health Care Management, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia. Email:
authors.forename: Judith
authors.initials: J
authors.lastname: Dwyer
authors.affiliation: School of Health Sciences, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia. Email:
authors.forename: Eileen
authors.initials: E
authors.lastname: Willis
authors.affiliation: Department of Health Care Management, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia. Email:
authors.forename: Janet
authors.initials: J
authors.lastname: Kelly
mesh_terms: D005260:Female; D006291:Health Policy; D054625:Healthcare Disparities; D006780:Hospitals, Rural; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D036301:Qualitative Research; D013021:South Australia