When All You Have is a Hammer, Everything Looks Like a Nail: A South Australian Perspective on Cultural Safety and Engaging the Unengaged

Quality in health care is a multidimensional concept, and it is widely considered to be underpinned by six key components such as safety, effectiveness, efficiency, timeliness, equity, and patient centeredness. In recent times, there has been increasing focus on patient-centred care, also referred to as client-centred care and/or consumer-directed care. This has been also been driven by the integration of evidence-based practice in health care, which calls for the integration of patient’s morals, values, and beliefs with best research evidence, clinical expertise, and practice context. While this has been widely accepted from a philosophical point of view, practically, how does one go about implementing patient-centred care and build on patient’s morals, values and beliefs in the contemporary health system?

Over the past few months, I have been collaborating with a group of occupational therapists who work in mental health at the Country Health South Australia Local Health Network (CHSALHN). These occupational therapists, in partnership with fellow health professionals at CHSALHN, have tackled this very issue of implementing patient-centred care at the local health network. This is their story.

It is now widely acknowledged that health is more than simply the presence or absence of physical conditions or illnesses; it also incorporates mental health and social and emotional wellbeing. It is well established that the health and wellbeing of many Aboriginal Australians is well below that of other Australians on a range of health and social indicators, and access to health services remains an ongoing issue, particularly for those living in rural and remote areas.1 This is despite the fact that the Australian Government’s "Close the Gap” campaign, which aims to increase access to health services to prevent ill health for Aboriginal Australians. Complexities and challenges arise with such vast differences in rural populations and varying geographical, physical, and social aspects.

Mental health professionals utilise an evidence-based practice approach that aims to provide client-centred intervention with a particular focus for occupational therapists to the individual’s characteristics, the environment, and the occupation. This lead to the question, "Are we (occupational therapists) culturally safe in our occupational therapy (OT) clinical practic, when working with Aboriginal Australians?” This resulted in a project in which OT practice was reviewed for its cultural safety on the Inpatient Psychiatric Unit (IPU) with an aim to assist Aboriginal Australian clients to better understand their mental health problems and develop their occupational goals.

Here is a fictional case study of a commonly encountered clinical scenario: A young Aboriginal man, Jonah (not his real name), is brought into the clinical, sterile surrounds and sounds of our IPU, which is a state wide psychiatric service for all country South Australians located in Adelaide. He is transferred involuntarily under the state’s Mental Health Act from the Anangu Pitjantjatjara Yankunytjatjara (APY) lands, 1100 km northwest of Adelaide, South Australia. His home lands of Kaltjiti are vast with red sand and unpaved roads, with one general store supplied fortnightly by road train providing the locals with non-perishables, frozen kangaroo tails, and soft old fruit that has travelled for two days on the dirt roads. There is one health clinic and one school for the population of approximately 350 people, and the nearest community is 80 km away. So when Jonah arrives at the psychiatric IPU, what does he see? Does he see acknowledgement and an understanding of his traditions, his home land, and his culture? The sights and sounds are unfamiliar and anxiety provoking, and there is a clinical language used that is at best disempowering and confusing. The multi-disciplinary team is trying to do its best, but the system is falling well short of supporting the most disadvantaged people in our state, and we, the occupational therapists, yet another white- faced worker on the ward, acknowledge we need to do better. It poses the question, how does one assess and meet the occupational needs of this man when our only tools are westernised, clinical in nature, and culturally insensitive?

We initially posed the question, "Are we (occupational therapists) culturally safe in our occupational therapy clinical practice on the IPU?” Certainly there was a recognised and expressed unease or under-confidence associated with being able to assess Aboriginal Australians on the inpatient unit. Initial discussions with other occupational therapists led to further exploring the difficulties we had with engaging Aboriginal Australians. To put it simply, occupational therapists were struggling without the appropriate clinical and culturally safe assessment tools. It was also apparent that health professionals, in addition to being culturally aware, should also be culturally competent. Cultural competence relates to ensuring occupational therapists have the skills and knowledge to work with Aboriginal Australians in a culturally competent manner, but this does not explicitly imply these competences are translated into clinical practice. This led to the participation in a project in which occupational therapists focused on the term cultural safety by recognising, respecting, and nurturing the unique cultural identity of Aboriginal people and attempting to meet their needs and expectations.2 Cultural safety implies that occupational therapists are "doing” or demonstrating culturally safe skills and knowledge in clinical practice.

Modifying and tailoring practice to enable a culturally safe clinical practice has been recognised in health-care generally, and occupational therapy specifically, as means of achieving equity in outcomes for Aboriginal Australians in the IPU.3 However, when delivering health care to Aboriginal Australians, there is recognition that there are limited culturally safe assessment tools accessible, and there is a paucity of Aboriginal specific mental health occupational therapy assessment tools. Therefore, occupational therapists used commonly available tools even though they were not specific to meet the requirements of Aboriginal-specific mental health issues. The old adage, "When all you have is a hammer, everything looks like a nail” signifies in essence that occupational therapists did their best with the tools they had with whomever the person or whatever the situation or experience. Ultimately, though, not having the most appropriate assessment leads to not getting the best information to be able to guide interventions for recovery from an occupational perspective. Many of the occupational therapy standardised assessments in current use do not have a cultural specific focus because of a lack of consideration of indigenous culture in design and language.4 This is a significant barrier in our attempts to clinically engage the unengaged.

In order to achieve better outcomes for Aboriginal Australians with mental health difficulties through cultural safety, the occupational therapists needed to critically review the cultural safety of their occupational therapy practice. Occupational therapists were provided with training in The Clinical Practice Improvement (CPI) which provided the structure and methodology to address our identified problem. This was then followed by engaging with key stakeholders, who through brainstorming identified contributing factors to the problem, and established a project team which set about to form recommendations and actions to improve OT’s cultural safety when working with Aboriginal Australians on the IPU. A significant component of the culturally safe clinical practice improvement project was to choose one of the many relevant mental health occupational therapy assessment tools and adapt it to be culturally safe for local regions. With permission from the developers, a self- assessment (Occupational Self - Assessment (OSA) based on the Model of Human Occupation (MOHO) framework, which explores an individual’s personal values and their personal causation of different activities of daily living, was chosen. The OSA was based on the principle that each client is a unique individual whose particular values and sense of capacity should determine the nature of occupational therapy intervention.5 To review and address the cultural safety of this assessment, the occupational therapists undertook community consultations with aboriginal elders representing several "countries” (Australian Aboriginal regions) and took their recommendations back to the project team to continue to guide the modifications. This was an iterative process until all required changes to the OSA assessment were made.

The modified assessment now provides relevancy and culturally safe language which will enable it to be utilised more effectively with Aboriginal Australians in the IPU. The modified assessment will encourage a strengthening of the often unheard or misheard voices of Aboriginal Australians. In conjunction with the development of the culturally safe assessment, a local work site procedure was also developed to guide a consistent occupational therapy practice that supports culturally safe engagement and service delivery. The procedure outlines relationships within the multi-disciplinary team and incorporates three stages of the occupational therapy practice involving the assessment phase, the therapeutic group program, and individual interventions. At each stage, a simple PDSA (Plan, Do, Study, Act) evaluation was utilised to determine the effectiveness of this strategy.

This cultural safety project has significantly improved the confidence and ability of occupational therapists to engage with Aboriginal Australians who are clients in the IPU. It has enabled improved assessment, enhanced treatment planning, and effective discharge planning. The modifications to practice have also emphasised the importance of gathering information and working with each individual in a unique, respectful and culturally appropriate manner.3 This project is a good example of health services research which is driven by gaps in clinical practice and championed by health professionals that results in an outcome which is readily implementable and sustainable. While numerous evidence-practice gaps continue to persist in health care today, initiatives such as these provide a glimpse of how projects which are developed at the coal face, in response to issues confronting health professionals, could play an important role in addressing the evidence-practice gaps. Furthermore, the next time a young Aboriginal man or woman, like Jonah, comes down from the APY lands or somewhere else in country for that matter, there will be some recognition from them that out of all of the unfamiliar faces they see on the ward, there really is an attempt to respect and understand their culture and needs. And that can only be a good thing when trying to engage the unengaged.


  1. Nelson A, Gray M, Jensen H, Thomas Y, McIntosh K, Oke L, Paluch T. Closing the gap: supporting occupational therapists to partner effectively with First Australians. Australian Occupational Therapy Journal. 2011;58:17-24.
  2. Cultural Inclusion Framework for South Australia [Internet]. Department of the Premier and Cabinet. SA: 2006 Available from: http://dpc.sa.gov.au/sites/default/files/pubimages/documents/aard/CIF_guide.pdf.
  3. Stedman A, Thomas Y. Reflecting on our effectiveness: Occupational Therapy interventions with indigenous clients. Australian Occupational Therapy Journal. 2011;58:43-49.
  4. Thorley M, Lim SM. Considerations for occupational therapy assessment for Indigenous children in Australia. Australian Occupational Therapy Journal. 2011;58:3-10.
  5. Kielhofner G, Forsyth K, Kramer J, Iyenger A. Developing the Occupational Self Assessment: the use of Rasch analysis to assure internal validity, sensitivity and reliability. British Journal of Occupational Therapy. 2009;72(3):94-104.


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