Aboriginal health workers

An illustrative example of workforce substitution

What might you want to know?

Bold attempt to create a new form of health workforce to not just fill a perceived gap but to deliver services better than traditional health professionals Strong links of the workforce to, and understanding of, the community being serviced How was the workforce created, developed & sustained Was the attempt successful?

Does this scenario sound familiar?

Many small communities (300 - 2000 people) needing to be serviced, with little capacity or willingness of the populations to move to larger population centres Limited infrastructure in communities poor housing, varied access to education, limited employment opportunities Most communities remotely located . Between 3 and 12 hours travel to nearest town with suitable health infrastructure worse in the rainy season.

A bit about the workforce

The workforce was first created in the Northern Territory in the 1960s The workforce was created by doctors and a small number of nurses that needed better access to communities (language / culture), to triage patients and provide follow up on treatment Initial training was largely inservice and onthejob and focused on developing high quality in a limited number of areas (mostly related to infectious disease ID and control) In the 1990s the workforce attempted to professionalise. A significant step was to become a registered profession Current registration entry requirements are a Certificate IV, completed though a fairly conceptual, educational institution based course, integrated with workplace based learning.

Workforce size & growth

Estimated currently between 300 and 350 heads Spread almost equally over government and community controlled service providers Approximately 85% work in primary health care 76% of the workforce older than 40 years old 72% of the workforce is female Almost 45% have been in their job more than 5 years Workforce size has remained fairly static since 2002

Comparatively stagnant growth when compared with other health workforces

2000 1900 1800 1700 1600 1500 1400 1300 1200 1100 1000 PP 05- PP 05- PP 05- PP 07- PP07- PP07- PP 09- PP 09- PP 091 13 26 1 13 26 1 13 23

Pay Period (yy-period number)

= Loss of identity

Recommended ratio (/ 100 population)

Registered Aboriginal Health Worker 0.86 full time equivalent; Registered Nurse - 0.86 full time equivalent; General practitioner - 0.24 full time equivalent; and Aboriginal Community Worker - 0.43 full time equivalent

Current actual ratio in primary health care (/ service)

Two nurses to every AHW

Relationships with other health professionals

AHWs see their role as an equal member of the health service team - a team that comprises at least doctors, nurses and AHWs who bring their own equally critical personal and professional skills to the service of the community in practice AHWs experience inequality with other health professional staff and are often perceived as the bottom of the pile. Many overt and covert aspects of health service life promote and reinforce this message.

Occupational health and safety issues

health problems of AHWs themselves e.g., diabetes and hearing problems; living in crowded housing with other family members who are not working and therefore interrupting the sleep of AHWs; humbug from family and community members, which in the case of AHWs working in their own community, can be significant and contribute to considerable occupational stress; emotional involvement of treating patients from within an AHWs own family or community (discussed in the literature as emotional labour); fear of payback from the community if a patient dies.

Ambiguous work roles

advocating for individuals and families, delivering interpreting services, cultural brokerage; assessing clients physical well being, providing a screening service, monitoring health care, working with medicines, maintaining medical records; providing first aid, responding to medical emergencies; providing and utilising traditional medicines; delivering counselling, supporting clients social and emotional wellbeing; providing environmental health care, collecting information on the communitys health, delivering health education and promotion, providing nutrition guidance for specific health care; planning and implementing health care, management, research, education and training;

HR difficulties the result of an ambiguous role

Preparation, training and professional development (the work defines the competencies required); Performance management (allocating work appropriately to optimal ability and supervising / managing performance); and Rewarding work completed (the work defines the level of responsibility and accountability).

Recruitment & training of AHWs

Recruitment to Aboriginal health work has traditionally been by community selection of appropriate community members with the correct status to undertake Aboriginal health work Recruitment therefore is from an increasingly limited pool of community based people with adequate numeracy and literacy skills who could realistically complete the requirements of the Certificate IV. Training has become increasingly demanding as AHWs seek professional status

Recruitment & training

The current training process requires long periods during the course away from home and family interspersed with periods of supervised work Clinical supervision on the job is poor, with neither the educational institution or the employer accepting responsibility Sufficient recruits to training can only be found in towns, breaking therefore the rule of community based selection

Career Progression including pay and conditions

Job classifications within the agreements for both government and Community Controlled Organisations are very narrow and there are few steps limited career path for AHWs who wish to move into management positions or specialist areas. Essentially AHWs need to move into another classification structure (or career path) in order to seek managerial opportunities. lack of structured professional development training programs tailored individually for all AHWs with career progression goals

Summary

Relatively shrinking workforce, becoming increasingly irrelevant Poor relationships with nurses, who do not value AHW skills Recruitment from communities increasingly difficult pool of talent is drying up Training is of variable quality, with poor completion rates and insufficient enrolments Pay is insufficient to act as an incentive and career pathways are unenticing

Where to from here? Should the AHW workforce be allowed to slowly become extinct? If not, what to do?

Training solutions

Creating regional training centres in larger urban and town centres, but still closer to service providers than currently the case. Regional centres need to be a collaboration of interests who are committed to sound training outcomes including health services, education institutions, and other dedicated training resources from the health system Ensuring each trainee AHW has a suitable designated supervisor/mentor in the health services, preferably in a community based service Ensuring sufficient and suitable AHW educators who will provide regular clinical support and on the job training to all AHW trainees by visiting all trainees in their health services Accepting that for some trainees the period of the training course could realistically be up to three years and include language and literacy alongside or as a prerequisite to the conceptual and clinical training of the Certificate IV.

Pay & condition solutions

9
Principal AHW Advisor

AHW Director

AHW Director

AHW Director

Level 7

Specialist or AHW physician assistant

Remote relief team

Senior public health adviser

AHW Regional Manager

Level 6

Communicable diseases specialist

Public health planner

Clinic Manager/HR role

Level 5

Emergency, oncall

Professional development supervisor

AHW educator and trainer

Level 4

Program work clinical role

Public health officer

Level 3

Cultural broker/ health promotion

AHW nonclinical

Level 2

Level 1

Trainee AHWs