Working in one’s own community can be rewarding but stressful; there is a perception that you are “everything to everyone”
Aboriginal health workers (AHWs) have usually lived in the community they work in and have developed lasting relationships with the community and with the various government agencies. One of us (M M) has lived in Townsville for 12 years and the other (L H) for 4 years (having grown up in the town of Hughenden, 370 km west of Townsville). These ties to the community and health networks provide us with a real sense of what is going on and what is needed at a grassroots level.
There are many reasons for AHWs choosing to work in an Aboriginal community controlled health service (ACCHS). The opportunity to work with their community, as mentioned, is a strong motivation. Others may be “head-hunted” (as we were) or may have practical reasons for wanting to move to larger centres. One of us (M M) gained a great deal of experience working as an enrolled nurse in a small regional hospital for 10 years and was looking for a new challenge. Working with the Townsville Aboriginal and Islanders Health Services (TAIHS) provided an opportunity to participate in a holistic health service planned by the community.
For others, it may be the opportunity to participate in research projects and community development projects. Some health workers at TAIHS have moved down from more remote areas, such as the Torres Strait, to be near their family and further their education.
Health workers at ACCHSs, unlike those in mainstream services, are free to use their clinical skills and are called on to perform a wide range of procedures. For example, we are able to administer childhood vaccinations under the supervision of a doctor, take Pap smears, take blood, and perform health checks. Opportunities exist to experience a broad clinical program or pursue an area of interest, whereas health workers in the government sector are often tied to specific clinical areas or to non-clinical work, such as transport and social assistance.
It has been very empowering as Aboriginal women to be involved in the many programs run through TAIHS. The ACCHS setting allows more autonomy in setting up and implementing health programs. At TAIHS, we have planned and successfully run programs such as a breastfeeding peer support program, a smoking cessation project, a human papilloma virus project (which has increased the number of women having Pap smear screening), and a walkabout project (increasing physical activity). These programs also allow for innovative approaches to raise awareness within the community. For example, at TAIHS, the health workers have initiated a community breakfast for breast cancer week, and participate in a weekly local radio health segment.
Health workers in ACCHSs also deliver outreach services to the wider community, including prisons, fringe camps and youth detention centres, and have the opportunity to travel to workshops and conferences to expand their knowledge and skills as well as build professional networks.
Inevitably, working in Indigenous health, there will be cultural clashes, but these are easier to mediate in the ACCHS setting. The state health system’s mainstream perspective, less flexible management, and lack of cultural sensitivity can make dealing with cultural clashes more difficult.
ACCHS health workers carry a great load of community expectation. We are asked to take on many roles at once, and are seen as being “everything to everyone”. Older staff members may not respect the contribution of younger workers; they may carry their role as elders into the workplace, and this can cause problems.
Working in the community sector involves working with multidisciplinary teams. Some professional staff — both nurses and doctors — can be ignorant of the AHWs’ skills and abilities, opting to work with a registered nurse instead. Difficulties in teamwork can be frustrating and can affect service delivery.
A continued source of stress is the lack of national qualifications and recognition of competencies of AHWs. For example, those trained in taking Pap smears and giving vaccinations can only use these skills in an ACCHS setting because their training is not recognised in other heath sectors in Queensland. Although AHWs are accepted into training courses, sit the same exams and develop the same level of competence, only registered nurses gain formal recognition across all sectors.
The health service union award, under which AHWs work, has not been updated since 1992. In the past decade, there have been significant changes to education for AHWs and increased levels of responsibility in the clinical environment. Remuneration in the community sector is not progressing in line with government-employed health workers. ACCHS health workers have higher levels of clinical skills and responsibilities than our colleagues in state health. Service delivery in the two sectors is very different, with state health focusing on a disease-model approach while the ACCHS approach is broader, encompassing a social model of health.
There are a number of enrolled nurses working as AHWs. This is because the training is short and hospital-based (and in remote areas it is more likely there will be a hospital than an ACCHS). When enrolled nurses move into ACCHSs, both parties are disadvantaged because, although enrolled nurses participate in care-planning activities, they are not issued with provider numbers and are unable to bill under Medicare.
Bearing the load of community expectation can be very tiring when combined with the responsibilities of work and family. We cannot go out after work and relax, as community members may want to unload their problems on us.
When there is family conflict in a community, people can distance themselves from the ACCHS if the health worker belongs to a different clan. There may be concerns that confidentiality is not adhered to, despite health workers being committed to professional codes of conduct. These issues can be frustrating and may damage health workers’ sense of their own professionalism. The community grapevine can add to the pressure by exaggerating things out of all proportion.
We are hopeful that we will finish our studies, complete our Bachelor of Nursing Science degrees and one day work as chief executive officers of TAIHS. As joint CEOs, we would strongly advocate for improving the recognition of AHWs and for more equitable pay structures, while continuing our work with the community.