Acute Coronary Syndrome (ACS) represents one of the most common causes of acute medical admissions to Australian hospitals [1
]. Patients with ACS have varying medical histories, diverse clinical presentations and are likely to experience a second serious cardiac event; they require acute in-hospital clinical care and experience high mortality rates [3
]. Management of ACS is targeted towards identifying those patients at higher risk of subsequent events and reducing or avoiding such events through revascularisation of the culprit plaque, where appropriate, and medical therapy to stabilise other at risk plaques [4
The incidence of ACS has increased and the outcomes of care for ACS have shown smaller improvement for Aboriginal and Torres Strait Islandera
Australians compared to their non-Indigenous counterparts [5
]. A national retrospective study on ACS management in Australia reported three striking failures and policy issues that were systemic: an evidence practice-gap; and concern about the capacity of the treating hospital and the continuity of care available [13
]. Many contributing factors lead to less than optimal health outcomes for Indigenous patients; these factors often lie outside the health system itself [1
]. For example, studies that compare Indigenous and non-Indigenous patients with ACS and or chest pain are inconclusive about the reasons for the differences in-hospital and survival rates. It has been argued that the difference in treatment and outcomes may be the result of more subtle systemic practices, not necessarily ill-intentioned but still discriminatory, and almost invisible within an individual patient-clinician encounter [14
]. These findings highlight the importance of quantifying and qualifying patient-clinician engagement as a possible explanation for the differential between Indigenous and non-Indigenous patients admitted to hospital for an acute cardiac event. A focus on health status, risk factors and clinical interventions may camouflage critical issues within a patient-clinician exchange. Broadening our understanding of the Indigenous in-hospital disparities and mortality, to include patient-clinician engagement may provide opportunities to close the gap in health attainment.
This Study Protocol identifies the gaps in knowledge pertaining to patient-clinician engagement, states the research aims and questions, describes the types of people that may participate in the research, outlines the methodology and methods used as well as highlighting the limitations of the study. The Study Protocol also situates this study within a boarder research program that explores the potential drivers that may influence the differential in health care and health status experienced by Indigenous Australians compared to non-Indigenous Australians who experience an acute cardiac event.
Patient-clinician engagement is shaped by a range of factors, not only to do with the agents’ personality and socioeconomic circumstances, but also the diagnosis and proposed management, and the context of the medical encounter. Influencing factors may present as a single factor or may have aggregated and distributive attributes. Figure illustrates the overall conceptual diagram for the research.
Conceptual diagram of the research.
National and international studies suggest three key areas influence the patient-clinician relationship: reflective clinical practice, a shared understanding and integration of health care; and cultural safety which lays the foundation for this interface.
Creating a culturally safeb
environment involves health professionals undergoing a reflective process of understanding the self and others. For example, one’s review of ontology (assumptions about the nature of reality), epistemology (the ways of knowing that reality), and axiology (the nature of values) [17
]. When health professionals become aware of how their understanding of the ‘other’ influences their clinical practice, they may facilitate opportunities for patients to engage ‘safely’
in the patient-clinician relationship [20
In Australia, studies that described the interaction between Indigenous patients and clinicians illuminate many of the nuances of the patient-clinician interface. Miscommunication, feelings of disempowerment, mistrust and racism were reported barriers to patient engagement [15
]. A summary of the factors highlighted in the literature that influence patient-clinician engagement and adverse consequences is outlined in Table . This list strongly suggests that patient-clinician engagement may be compromised in the case of Indigenous patients.
Factors that influence patient-clinician engagement and the adverse consequences
There is great scope for improvement in building a shared understanding in the patient-clinician interface. Australian studies reported a number of factors that influenced the quality of the patient-clinician relationship. The most common factor identified is miscommunication between the patient-clinician. Miscommunication often goes unrecognised, especially with regard to diagnosis, treatment and prevention [21
]. Possible solutions that may assist to overcome these barriers include: increasing the Indigenous health workforce; increasing access to interpreter services; and engaging with patients throughout the patient pathway (pre-operative; post-operative; long-term and secondary prevention). These possible solutions may contribute to ensuring culturally appropriate health education and mandatory training in cultural safety [15
]. The experiences described are not unique to Indigenous people; nonetheless they provide insights into the complexities that Indigenous people have to overcome when seeking health care.
Patient-clinician engagement: synergetic partnership
It is hypothesised that patient-clinician engagement is instrumental for improving health care and results in improved health outcomes. For the purpose of this study, patient-clinician engagement is explored and defined at the micro level. Patient-clinician engagement is the two-way interface between patient and clinician (individually and systematically). Patient-clinician engagement can manifest as an outcome but fundamentally it is the process that defines the outcome.
The patient-clinician interface is framed by interrelated variables such as: gender; age; personal heterogeneities (both patient and clinician); family and professional responsibilities; cultural orientation; socioeconomic position; lived experience; and respective cultural paradigms. The interface is further contextualised by, environmental diversities, social climate and differences in relational perspectives. Engagement is not homogeneous and is neither constant nor in any sense automatic. Patient-clinician engagement is about relationships. Essentially, patient-clinician engagement is the synergy between clinical competence, cultural respect and the shared understanding that occurs when health care providers’ acknowledge and nurture the wellbeing of the patient. Failure to invest in this relationship may result in adverse outcomes such as potentially life-threatening consequences for the patient and policy implications for health care providers [3
Adopting an Indigenous framework identifies the limitation of Western paradigms to adequately portray Indigenous realities, knowledge, intellects, histories and experiences. This study will apply an Indigenous framework to describe the interaction between Indigenous patients and clinician clinical encounters during an acute cardiac admission.
Indigenous knowledges and health status are often problematised and pathologised [18
]. Indigenous people are frequently positioned as being dysfunctional and challenging. This perpetuates a body of health research where Indigenous knowledges are disregarded. This deficit approach obscures the survival and resistance strategies employed by Indigenous Australians for over 220 years. Indigenous methodology makes it explicit that the study will be viewed through a culturally-specific lens that privileges Indigenous realities by taking account of Indigenous epistemologies and ontologies [18
By using an Indigenous methodology we can situate Indigenous peoples as the subjects of their experiences rather than objects of the research [23
]. Indigenous Australians think and interpret the world and its realities in different ways to non-Indigenous Australians because of their experiences, histories, cultures and values, which in turn influences their patterns of morbidity, mortality and health outcomes. Indigenous ways of knowing is a continuum because context is important and this is particularly important in an area where efforts from non-Indigenous researchers towards ‘knowing’ have often been intrusive and exploitative [22
]. Finally, cultural safety, cultural respect, cultural relevance and world view alignment is the nucleus to an Indigenous framework [24
1. How do Indigenous and non-Indigenous patients who were admitted for an acute cardiac event describe patient-clinician engagement?
2. How do clinicians who provide cardiac care to patients describe Indigenous and non-Indigenous patient-clinician engagement?; and
3. How can patient-clinician engagement improve cardiac care hospital admission and transition into secondary health care?
1. To describe patient-related factors, clinician-related factors and system factors that influence the patient-clinician engagement for Indigenous and non-Indigenous patients diagnosed and treated for an acute cardiac event in South Australia; and
2. To identify areas of potential improvement that may support patient-clinician engagement during and after admission for an acute cardiac event i.e. into secondary and rehabilitative cardiac care.