Design

Case study methodology underpins how we conducted this component of the research. Stake [35] describes case studies as “the intrinsic study of a valued particular”, where the object of study is selected “not because it is representative of other cases, but because of its uniqueness, which is of genuine interest” [36]. This approach was particularly relevant for the current study, where the services were selected because they were rated to be particularly high performing and innovative in their provision of cancer services for Indigenous cancer patients and their families in the first phase of the research. If done sensitively and appropriately, it has been concluded that there is value in using case studies in Indigenous research [37, 38].

Cultural and ethical considerations

Ethics approvals for the national study were obtained from the Western Australian Aboriginal Health Ethics Committee (WAAHEC) (approval number 483) and the Human Research Ethics Committees of University of Western Australia (RA/4/1/6286), as well as multiple other local ethics committees. Overarching ethics approval for the specific sites was obtained from the St Vincent’s Human Research Ethics Committee (approval number HREC/16/SVHM/94), with site-specific approval obtained through local ethics and governance processes.

The NHMRC Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research were adhered to [39]. The values of reciprocity, respect, equality, responsibility, survival, protection, spirit and integrity, were central to this research, and provided guidance to the design and conduct. Three members of the research team are Aboriginal women. These researchers participated in the design of the study, conducted interviews, and provided input into, and approved, the draft manuscript. Prior to commencing the case studies an Aboriginal Advisory/Reference Group was formed. This group had face-to-face meetings and provided email support and advice to the study. In addition, we consulted with peak bodies of Aboriginal and Torres Strait Islander Community Controlled Health Organisations.

Participant recruitment and profile

Recruitment was purposive with relevant staff, Indigenous cancer patients and family members identified by local health service staff and managers within each participating organisation. The site investigator ensured that all participants were informed and prepared prior to being approached by researchers for interview. Staff were invited to participate if they were involved with the care or support of Indigenous cancer patients or if they filled a leadership role in the care of Indigenous patients. Interview participation was voluntary and all participants were provided with information about the research and gave either written or oral consent prior to data collection. Participants were reminded that they could stop the interview at any time. Indigenous patients were encouraged to include a support person or family member to be with them during the interview process.

Twenty-four in-depth interviews were conducted with relevant hospital staff (n = 24). Fourteen participants worked at the Regional Service, ten participants were employed in the Urban Service. Participants included more women (n = 20; 83%) than men, and a third (n = 8) identified as Aboriginal or Torres Strait Islander. A diverse set of professions participated, including Indigenous Liaison Officers, Social Workers, Cancer Coordinators, Registered Nurses, Oncologists, Managers, Executives, and Administration staff.

Six in-depth interviews were conducted with Indigenous patients with cancer (n = 5; four male) and affected family members (n = 3; all female). Three patients and one family member spoke about their experiences at the Urban Service, two patients and two family members described their experiences with the Regional Service.

Data collection

Interviews were conducted between March 2015 and December 2018, mostly in-person (n = 25) but five were undertaken by telephone, and ranged in length from 30 to 90 minutes. An Indigenous researcher participated in all interviews with Indigenous patients and family members, which were all conducted in person. Interviews were conducted with the use of an interview guide, audio taped and transcribed verbatim. The interviews for the detailed service studies were conducted between September 2017 and December 2018 by four female researchers. Two of the researchers conducting interviews were Aboriginal women, both of whom have clinical backgrounds in cancer, and one of whom is an experienced researcher. The two non-Indigenous interviewers both have clinical backgrounds and over twenty years’ experience with collaborative research into improving Indigenous health outcomes. We also included four staff interviews from the original service interviews conducted between March and October 2015; these were conducted via telephone by one non-Indigenous female researcher with five years’ experience in Indigenous health research.

Three staff were interviewed twice, initially in 2015 as part of the original service interviews, and again in 2017 or 2018 as part of the detailed service study. The original interviews with these participants were included in the analysis as they offered rich additional insights into their service’s workforce approach. An interview with one key staff member was included from the 2015 study because they were on long leave, and therefore unavailable for interview during the detailed service study. On three occasions, two staff members were interviewed together for their convenience, and two patients chose to be interviewed with a family member. Health staff were asked about initiatives and programs to improve engagement with Indigenous people, specifically within cancer services, including questions on cultural awareness programs, cultural identifiers, Indigenous staff employment strategies and numbers. Indigenous people affected by cancer were asked about their experiences at the cancer centre and any suggestions for changes or improvements.

Additional information was gathered from the health service websites, including strategic plans, Reconciliation Action Plans and information on Executive and Board membership.

Data analysis

We used the thematic analysis process described by Green et al. [40] of immersion in the data and coding, with rereading and aggregation of identified themes. Initial coding was undertaken by an independent qualitative coder, who used NVivo 10 to help organise and extract relevant data, and identify initial themes. Discussions within the team further developed these themes. All interviews were then re-read and manually coded by a team member (EVT) using an Indigenous health workforce lens to develop existing themes and identify additional themes. The whole team then met to further refine themes and reach agreement on the final themes. Analysis was conducted to ensure that each theme could be traced back to the original data, using direct references from the interviews to provide evidence and maintain the voice of the participants. Provisional data interpretation was checked with key stakeholders at each service, with feedback and additional information incorporated into the final analysis. All authors had input into and approved the final manuscript.

Executive leadership

The Executive team in both health services demonstrated a strong and positive commitment to improving Indigenous health outcomes, strengthening the cultural safety of their health services, and to supporting and growing their Indigenous workforce. Both services have made improving Indigenous health outcomes a key commitment of their strategic plans and both have a Reconciliation Action Plan (RAP) containing multiple action items on increasing Aboriginal and Torres Strait Islander employment. The Urban Service is operated by a national not-for-profit healthcare provider, and their RAP “is the overarching strategy document to empower Australia’s First Peoples” for all health care facilities that the national organisation operates. The national organisation commissioned a painting representing their RAP, which was a collaboration between three Indigenous artists and 48 staff from the three states where the health care facilities are located. The artwork is now displayed in each facility, including in multiple areas of the Urban Service, publically highlighting their commitment to the RAP. Progress on the RAP was on the agenda and discussed at every Executive meeting.

The Regional Service has Indigenous leadership at the highest levels, with an Executive Director of Aboriginal and Torres Strait Islander Health, a Board member who identifies as Indigenous, the requirement that a member of the Clinical Council must be Indigenous and an Aboriginal and Torres Strait Islander Community Advisory Council.

While the Urban Service does not have Indigenous representation on the Executive, comments from multiple participants showed that Executive support is felt by staff on the ground, epitomised by the comment “We certainly do have the support of executive members to do what we need to do to have good outcomes” (Participant 7, Manager, Indigenous). Furthermore, the Executive team of this service engages directly with the Indigenous health workforce by holding an offsite annual forum to engage with all Indigenous staff members (including support staff). The first day of the forum is attended by members of the Executive team who talk with and seek feedback from staff. This engagement affirms that Indigenous ways of working are recognised and valued at senior level, as captured by one participant recounting an interaction at the forum:

“We had a guy who started in gardens and is working in maintenance … We were sort of having a bit of a yarn and he said, you know, ‘I see community members while I’m working and I’ll say hello and I probably shouldn’t’ and [the CEO] said, ‘No, you should. That improves the culture of the hospital as you have just identified. They feel culturally safe coming in and they can have a yarn to the maintenance guy who they know and who potentially they call uncle, but you are contributing to the cultural safety of the place, so don’t stop.’ So, to hear that from the high level CEO is pretty awesome.” (Participant 8, Manager, Indigenous)

Employment strategy

Compared to most other hospitals included in the initial survey of cancer services, the two health services employ a large number of Indigenous staff members including in identified Indigenous roles. At the time of writing, the Urban Service employs 52 Indigenous staff, 0.9% of the total workforce. The Regional Service employs 241 Indigenous staff, 3.74% of the total workforce. Both services have specific and measurable targets set for the employment of Indigenous staff. The Urban Service was aiming for a state population parity target of 1% by the end of 2018, and 3% by 2022. The Regional Service has a target of 4.5% by the end of 2022, with a stretch target of 8% (equivalent to the population proportion).

In 2015, the Urban Service published an “Aboriginal and Torres Strait Islander Employment Plan”. Connected to the RAP, this plan outlined objectives and an implementation framework for the whole organisation. Each section contains multiple action items with assigned responsibilities, timelines and targets. In 2019, this service implemented a cultural leave policy, an action item in the employment plan, which provides Indigenous staff with access to paid 4 days cultural and ceremonial leave. At the time of writing, the Regional Service was in the process of developing an “Aboriginal and Torres Strait Islander Workforce Strategy”.

The Urban Service also demonstrates their commitment to increasing their Indigenous workforce through the existence of an identified role within the human resources (HR) department responsible for the recruitment and retention of Indigenous staff across the health service. This service regularly advertises an Expression of Interest for Indigenous staff on their careers portal, encouraging applicants for both clinical and support service positions, with the statement that any Indigenous applicants “who can demonstrate that they meet the essential position criteria will automatically proceed to interview”. Furthermore, the service has a successful and rapidly growing Indigenous Cadetship Program, and a Graduate Nursing Program that supports Indigenous nursing students through the application process for Graduate positions.

Indigenous health unit

Both health services have an Indigenous Health Unit, Indigenous-led, which is responsible for managing the ILOs, supporting all Indigenous staff, designing and delivering cultural awareness training and quality improvement. The Urban unit was only established in 2016, after the initial data collection for the cancer services study was undertaken, and at the request of the service the detailed study of the service was delayed until after the Unit was established. Importantly, both units reported adequate autonomy and independence to ensure that “what we do is Aboriginal led” (Participant 10, Project Officer, non-Indigenous). The manager of one Indigenous Health Unit describes the management of the unit: “I have autonomy to sort of set the agenda and say, ‘This is where we are going’” (Participant 7, Manager, Indigenous).

The Indigenous Health Units play an important role in managing and supporting Indigenous staff, particularly ILOs. Historically, in both services, the ILOs were based and managed on the wards where there were less opportunities to connect with other Indigenous staff members and they were unlikely to have an Indigenous manager. Both services have moved to the model of a centrally managed Indigenous team so ILOs have an Indigenous manager as well as a team of Indigenous colleagues with whom to network and debrief. A member of Executive at the Urban Service explained some of the reasoning behind this: “…to get more of a profile around the unit, to have their own identity… and not as an exclusion thing, you know. It is a support thing.” (Participant 9, Executive, non-Indigenous)

Management stressed the importance of the Indigenous Health Unit in defining the ILO role and scope of practice to ensure that ILOs were not asked to work outside their role, with the aim of preventing staff from being overworked or suffering from burn out.

“We’ve also been careful that really defining the scope of practice for the Aboriginal liaison officer and making sure that they work within their scope of practice and that they are not pulled in a million different directions to do things that are not” (Participant 7, Manager, Indigenous)

Another benefit of the centrally managed Indigenous Health Unit mentioned by staff was better allocation of workload across the team, allowing staff members to cover each other, provide back-fill for training or leave and helping to prevent staff becoming overworked.

“We meet every morning now. If somebody is away, ‘Who will take this?’ you know, ‘Who will look after this ward?’ and that phone is given to whoever is going to do that. So it is a shared responsibility now.” (Participant 17, ILO, Indigenous)

Indigenous liaison officer

One factor of the ILOs’ role reported by Indigenous and non-Indigenous participants was their “automatic” involvement with any Indigenous patient, usually on the patient’s first visit. While reported by staff in the oncology ward, it was evident that this occurred widely at both health services, showing respect and valuing of the ILO role across these health services. In both cancer services, important system functionality had been developed which helped with both workload allocation and in ensuring that no patients were missed, with ILOs readily able to print off a list of all Indigenous patients within the service. In the Regional Service, one of the ILOs had recently instigated this improvement to the system.

Participants described many facets of the ILOs’ role, with a widely expressed view that the ILOs were the “linchpin” who “joins the dots between all the players: family, patients, community, hospital staff” (Participant 10, Project Officer, non-Indigenous, 2015 interview). ILOs fulfilled an important navigator or care coordinator role as well as family liaison.

“When the patients come in, the Aboriginal Liaison Officers do come in with the patient… They do act like navigators. They bring them in. They go and book the forms and book that, book this. They kind of take them through. So they do take on a care coordination role.” (Participant 13, Oncologist, non-Indigenous)

ILOs reported feeling empowered to advocate for their patients with the doctors to ensure that patient’s wishes (such as choosing to discontinue with treatment or returning home to die on country) were upheld.

“I had another old chap, he was palliative and he wanted to go home… And it was just advocating with doctors, because they were saying, ‘Oh, he has got some diabetes trouble’. Well, you know, he doesn’t care about his diabetes. You know, he only just got home. We got him home and that was on the Friday … Well, he passed on Sunday.” (Participant 17, ILO, Indigenous)

Multidisciplinary team inclusion

ILOs were valued members of the multidisciplinary team, attending regular clinical meetings and speaking on behalf of Indigenous patients.

“We have a Wednesday haematology meeting, and so all the patients on the ward, the ILOs would know all the patients that are Aboriginal and Torres Strait Islander patients and they would be expected to speak up for that patient, and they are very, very valued.” (Participant 20, Social Worker, non-Indigenous)

Joint patient assessments conducted by a Social Worker and an ILO were “expected”. Social Workers perceived benefits such as improved cultural safety for the patient and having a respected “cultural expert” to help them advocate for the patient.

Every time I have got someone who is Aboriginal I always have them [the ILO] introduce me as part of that cultural safety and appropriateness. So I don’t just go in; I get introduced. They are there with me when I do my assessment. They bring the cultural safety component, where I do the social work assessment component, and so we work as a team with the patient, and having that cultural respect and sensitivity the whole way. (Participant 3, Social Worker, non-Indigenous)

Staff stressed the importance of an informal, collegial relationship with their ILO colleagues, where they could “pick up the phone and chat… and know you can have that really collegial conversation about how we are going to work together to support this patient” (Participant 2, Social Worker, non-Indigenous) or “just knock on the door and you go in and talk about a case, or vice versa” (Participant 20, Social Worker, non-Indigenous). These close relationships were aided by a historical shared management structure (where the ILO team had originally been managed by the Social Work department) or close physical location, where daily informal exchanges could naturally occur.

Doctors and nurses regularly sought input from ILOs regarding Indigenous patients. As one ILO describes, “Doctors will call us while in the consult room and they will say, ‘Can you come?’” (Participant 17, ILO, Indigenous). This was considered unusual, as one participant observed, “you don’t see everywhere” (Participant 2, Social Worker, non-Indigenous).

The feeling of being a valued member of the team was summarised in this comment made by an Indigenous staff member:

“But all discussions around our Indigenous patients, we're part of the discussion in those meetings. Yeah they always look to us around what's going on. And even though the social workers are involved. And referrals, yeah new referrals we will be part of…. I mean our referrals are direct from the consultants too. You know we get e-mails from them, we get phone calls from them. So we're very much a part of the team here.” (Participant 24, ICC, Indigenous)

Professional development and two-way learning

Both services prioritised training opportunities for Indigenous staff. Career development for Indigenous staff was an action item on both RAPs, with one service aiming to develop career pathways and the other service targeting 100% of all Indigenous staff to develop a career plan with their manager as part of their annual performance plan. Indigenous staff were encouraged to consider their career pathway and were supported to achieve higher qualifications:

“It is about growing people, not just filling a plug in a hole. So ‘This is a pathway for you. Have you thought about doing nursing? Have you thought of doing allied health?’ So we are constantly moving people forward. That’s the goal.” (Participant 9, Executive, non-Indigenous)

“We do have one [ILO] currently who is doing a nursing degree. She is in ED, and then there was another one. She only recently left, but she is doing her social worker degree… Yeah, they [the hospital] do encourage us.” (Participant 17, ILO, Indigenous)

ILOs were encouraged to develop a specialisation and attend training in that speciality area. One ILO in the Urban Service and three ILOs in the Regional Service worked primarily in the oncology ward, which enabled them develop expertise in oncology, build relationships with the oncology team and become familiar with the patients and their specific needs. A staff member at the Urban Service describes these benefits:

“With [ILO], her specialisation is in renal and cancer care… so what that means is they get more embedded into teams and there is more input into developing their knowledge and skills for working in a particular area of care…. We want that worker [ILO] to have job satisfaction. We also want them to develop expertise. So today [name], who’s our cancer ILO, she’s off doing a two-day workshop [on cancer for ILOs]” (Participant 10, Project Officer, non-Indigenous)

Both services described informal mentoring for ILOs. The Urban Service followed a “Working Together” model of two-way learning and experiential learning, “you have dialogue, you learn from each other” to build the capacity of both the ILOs and the non-Indigenous clinical staff:

“I’m very, very lucky that we have our two-way learning model and that I work so closely with social work.” (Participant 4, ILO, Indigenous)

“There is still a lot of mentoring and supervision that comes out of social work or other disciplines … But, again, it is always two-way. It is not all that sort of top-down that the professional social worker or nurse is the teacher. It works both ways, so we continue to learn.” (Participant 10, Project Officer, non-Indigenous)

Both services actively support the development of the future Indigenous health workforce by providing clinical placements and mentoring specifically for Indigenous students studying in the fields of medicine, nursing and allied health. The Urban Service has a successful and rapidly expanding Indigenous Cadetship Program and a Graduate Nursing Program. The Indigenous Cadetship Program is government funded and offers second and third year Indigenous nursing and allied health students paid employment beyond their clinical training. This program sits within the Indigenous Health Unit, ensuring a culturally safe entry point into the hospital program for Cadets. The Graduate Nurse Program offers a seamless transition into nursing for Indigenous nursing graduates, and involves two six-month rotations.

“The idea is to bring Aboriginal students in and give them exposure working in a hospital environment in order to better prepare them for the workplace… We are hopeful these cadets come back to us through the graduate nursing program and build a career here … We want to give them exposure so they know what to expect” (Participant 7, Manager, Indigenous)

Work environment

Both services have made an effort to develop a culturally safe work environment with physical representations of respect incorporated and measured in multiple action items in both services’ RAP. This respect includes prominently displaying the Aboriginal and Torres Strait Islander flags throughout the hospital including at the entrance and with small flags on reception desks, artwork painted by local artists on the walls, and posters promoting Indigenous health with photos of staff members. Both services had policies specifying that an Acknowledgement of Country plaque is displayed at the entrance to the service, and that an Acknowledgement of Country is undertaken at all meetings.

Clothing was another physical expression of respect. In the Urban Service, the ILOs have their own uniform, making them easily identifiable to other staff and patients and seen as a way of legitimising the role. In the Regional Service, an Indigenous cancer patient designed a t-shirt that is worn by many staff members as a way to show support for Indigenous health:

“Yeah, all the radiation people have got one [T-shirt], yeah. One of our patients designed that for us. The pink part is the pink ribbon for breast cancer and the blue one is the blue ribbon for prostate cancer, and then, yeah. We particularly wear that on Friday that shirt; that is our Friday shirt” (Participant 23, Administration Officer, non-Indigenous)

Both services hold cultural events at significant times of the year, such as Reconciliation Week and NAIDOC week (annual Australian observances celebrating the history, culture and achievements of Indigenous peoples). Action items in their RAPs encourage staff to participate in such events, and remove barriers to staff attending cultural events. A staff member at the Urban Service reported that organising cultural events was a shared responsibility and a way of building relationships between Indigenous staff and non-Indigenous staff: “It’s not just ALOs doing it. There’s a whole lot of staff from the hospital helping to run it. And the beauty of it is that working together experience” (Participant 10, Project Officer, non-Indigenous). In the Regional Service, an Elder who was also an ILO at the service had conducted smoking ceremonies at significant events, such as when the new palliative care centre opened.

Both services provide cultural awareness training to increase staff knowledge and understanding of Indigenous peoples' cultures, histories and achievements. An action item in the RAP of both services was to ensure that the training program is mandatory for all staff. To meet this aim, Indigenous staff at the Urban Service have developed an online training module, which has currently been completed by 84% of all staff. In addition, a Learning Coordinator employed in the Indigenous Health Unit is responsible for delivering face-to-face cultural awareness training.

Culture of respect

The deep respect felt for Indigenous staff at these services came through strongly in every interview. Indigenous staff reported feeling respected and supported: “My opinion and my judgment is respected and what I am suggesting about how we move forward is considered” (Participant 7, Manager, Indigenous). “I don't know how they'd go without us really” (Participant 24, Cancer Coordinator, Indigenous).

This deep respect felt by non-Indigenous staff members towards Indigenous colleagues was expressed at all levels of the organisation. A member of the Executive team made this observation about an ILO: “She doesn’t want to be any trouble, but I mean I would walk on hot coals for her” (Participant 9, Executive, non-Indigenous). An oncologist described the ILOs as “just gold” (Participant 14, Oncologist, non-Indigenous). Recurring comments reiterated this esteem: how lucky they were to have their Indigenous staff members, how much respect they felt for their Indigenous colleagues and that the opinions of their Indigenous colleagues were sought and valued. “They are respected absolutely on their own grounds and their opinions are sought across many, many disciplines” (Participant 2, Social Worker, non-Indigenous).

Outcomes

Participants described multiple advantages to having a strong Indigenous workforce within their health service with both improved Indigenous patient outcomes and improved staff outcomes.

Gaps and continuous improvement

This study is cross sectional and reports on the services, their programs and progress, at a particular point in time. Both services were aware of areas where they wanted to improve and were actively and continually trying to improve Indigenous health outcomes, strengthen the cultural safety of their health services, and support and grow their Indigenous workforce. Both services demonstrated this commitment through new policies and procedures that were under development at the time of writing, such a new RAP (Urban Service) and an “Aboriginal and Torres Strait Islander Workforce Strategy” (Regional Service). In addition, the Urban Service employed a member of the Indigenous Health Unit whose role included a focus on continuous improvement for Indigenous health.

Despite the efforts of both services, gaps in the areas of recruitment and orientation were discernible from the interview data. One participant spoke at length about the recruitment process at the Urban Service. He described how the process and position requirements were discouraging and led to Indigenous people not applying (because they believed they weren’t eligible) or eligible candidates not being considered for a role because they didn’t hold a required qualification (even though their previous work experience rendered them eligible). However, a chance discussion with a colleague from HR led to the General Manager of HR seeking feedback from this participant about their experience with the recruitment process:

“I get this email from [the head of HR] saying… ‘What were the issues for you as an employee applying for a job at [health service]?’ And I said, ‘Well, you know, the process.’… ‘How hard was it to fill out the application?’ and I said, ‘It was a nightmare. You know, the first thing I looked at was you need a degree and I ain’t got that, so there’s no point in me putting in for it.’” (Participant 8, Manager, Indigenous)

Action items in the Urban Service’s “Aboriginal and Torres Strait Islander Employment Plan” and the Regional Service’s RAP show that the services are aware of, and working to address this gap. Targeted action items include: “assess current recruitment processes and identify barriers for Aboriginal and Torres Strait Islander job-seekers”, “offer all Aboriginal and Torres Strait Islander applicants the option of including an Aboriginal and/or Torres Strait Islander panel member on selection panel” and “interviews to be held in a relaxed environment that includes cultural recognition, Aboriginal and Torres Strait Islander flags and artwork”.

Orientation programs for new employees was another area where the data suggested opportunities for improvement. Indigenous staff members at both services talked about how “overwhelming” and confusing it was to start a new role with minimal orientation, training or handover. One staff member did not realise that she was only employed on a six-month contract when she started with the service (although her role had since developed into a permanent position). When asked about orientation, this participant laughed and responded, “I started on December 17… So I’m here for not even a week, I think, and the other liaison officers go on leave. And so I’m here by myself and ‘Shoot! What the hell!’” (Participant 4, ILO, Indigenous). Another participant described the challenge of joining the service to undertake the newly created role of Indigenous Health Unit Manager:

“Yes, it was a little daunting because the tricky part is you don’t have a predecessor to sort of -- You know, there are no handover notes or anything like that. It was a little bit of a choose-your-own-adventure to begin with but you are also coming into a hospital environment where you’ve got more responsibility in your role. It was tricky having to learn the business and then also get an idea of what was going on with my job.” (Participant 7, Manager, Indigenous)

Action items in the Urban Service’s “Aboriginal and Torres Strait Islander Employment Plan” such as “include Aboriginal and Torres Strait Islander employment and cultural safety to general orientation” and “extended orientation program for Aboriginal and Torres Strait Islander employees to [health service] provided as required” show that the service is working to address this gap. The Regional Service’s RAP has an action item to “develop strategies for supervision and mentoring for new and existing Aboriginal and Torres Strait Islander staff”.

Recommendations

Health services have an important role to play in supporting and growing the Indigenous health workforce. The strategies and actions captured in Fig 1 can be used by health services and cancer services to inform their own policies, programs and resourcing to support building their own Indigenous workforce. Where a recommendation below aligns with an Action in the Australian NSQHS Standards, the action number is given in brackets. The NSQHS Standards User guide for Aboriginal and Torres Strait Islander health suggests additional strategies for health service organisations seeking to improve the quality of care and health outcomes for Indigenous people and support their Indigenous health workforce [48]

Health Service Recommendations

• Demonstrate commitment to improving Indigenous health outcomes and achieving Indigenous health workforce equity via the development and proactive support of a mission/vision statement and appropriate policies and processes, including a Reconciliation Action Plan. (NSQHS Actions 1.2 and 1.4 [44])
• Develop knowledge and understanding of the current Indigenous workforce to inform future employment and professional development opportunities. (NSQHS Action 1.4 [44])
• Increase engagement with Indigenous staff, patients and communities and seek input on Indigenous health, system function and workforce development activities. (NSQHS Action 2.13 [44])
• Create a welcoming physical environment through the display of Acknowledgement of Country plaques at building entrances, Aboriginal and Torres Strait Islander flags, and local Indigenous artwork in all departments. (NSQHS Action 1.33 [44])
• Assess current recruitment processes and remove barriers for Indigenous job-seekers.
• Develop a culturally considered welcome to the organisation, such as including cultural safety expectations in the general orientation.
• Create a supportive environment for Indigenous employees through initiatives such as establishing an Indigenous employee network or providing access to culturally safe mentoring relationships.
• Encourage all Indigenous staff to develop and action a career plan with their manager and develop appropriate career pathways for Indigenous staff.
• Ensure all staff complete mandatory health-focused cultural awareness training, with completion embedded into performance management and/or professional development requirements. (NSQHS Action 1.21 [44])
• Hold and participate in cultural events at significant times of the year (such as NAIDOC Week and Reconciliation Week), with encouragement for all staff to participate in these events.
• Create ongoing Indigenous traineeship positions and cadetships.
• Incorporate data collection, analysis and evaluation into new strategies and programs with the publication of results where possible.
• Take time to listen to Indigenous staff around their thoughts on potential service improvements and work to implement their recommendations

Cancer Service Recommendations

• Implement systems to ensure that ILOs and IHWs are notified of new Indigenous cancer patients.
• Invite ILOs and IHWs to multidisciplinary meetings and give them the opportunity to provide input on their patients.
• Provide ILOs and IHWs with professional development opportunities such as in-house workshops and mentoring, external training and conference attendance.
• Ensure that staff follow the two-way learning model to build the capacity of both the Indigenous and non-Indigenous staff through opportunities for mentoring and working together.

Government also has a role in delivering and supporting effective schemes that provides incentives and financial support for health services to develop Reconciliation Action Plans, Indigenous employment policies and Indigenous cadetships and graduate programs.

Limitations

The original intention was for this study to utilise a mixed methods approach, and to incorporate quantitative data such as patient pathway timeframes to support the qualitative data. However, there were a number of delays with this project as well as challenges with approval processes and timeframes, which led to reduced capacity and meant the quantitative component of the research was not progressed.

We interviewed only eight Indigenous people affected by cancer, with several factors contributing to this. These are vulnerable people, so participants were only approached if it was felt their state of mental health and physical well-being was adequate; this limited the number of participants approached. A number of Indigenous patients agreed to be interviewed, however, on the day of the scheduled interview they were unavailable due to poor health or recent discharge.