Preparing students for placement in Aboriginal health services using online virtual orientation tours: A Participatory action approach

Cross M¹*, Sculthorpe J², Barnett T³, Dennis S³ (2017)

Preparing students for placement in Aboriginal health services using online virtual orientation tours: A Participatory action approach. Australian Indigenous HealthBulletin 17(1). Retrieved [access date] http://healthbulletin.org.au/articles/preparing-students-for-placement-in-aboriginal-health-services-using-online-virtual-orientation-tours-a-participatory-action-approach

1. Centre for Rural Health, University of Tasmania
2. Tasmanian Aboriginal Centre
3. Centre for Rural Health, University of Tasmania.

* Corresponding author’s contact details: Merylin Cross, Centre for Rural Health, University of Tasmania, Newnham Drive, Locked bag 1322 Launceston, Tasmania 7250, email: Merylin.Cross@utas.edu.au

Acknowledgements

The Tasmanian Aboriginal Centre was funded for this project by the Tasmanian Clinical Education Network through Health Workforce Australia. We acknowledge the valuable feedback provided by participants.

There were no conflicts of interest.

Abstract

Objective: To co-construct a virtual web-based platform to enhance the preparation of health care students for placement in Aboriginal health settings.

Methods: A Participatory action project undertaken in 2014-15 in Tasmania, Australia. Participants were an Aboriginal community controlled organisation, its Aboriginal Health Services and rural health academics at an Australian university.

Results: Virtual orientation tours of three Aboriginal Health Services were viewed 1,500 times within 12 months of being uploaded online in 2015. Collaboration was central to producing a mutually-useful, culturally-informed online resource that met the needs of placement and education providers for preparing students for placements in Aboriginal health. Partners and faculty that manage undergraduate placements valued the consistency, reach and flexibility the tours afforded.

Conclusions: Co-constructed virtual orientation tours provide a resource effective way for placement and education providers to augment the practical, cultural and ethical preparation of students for placement in Aboriginal health. Providing all health care students from any education provider, timely and flexible access to virtual tours of Aboriginal health services can demystify these services, attract interest in-context and begin orientation prior to arrival.

Implications: Virtual tours of Aboriginal health services may better prepare students for placements and facilitate more positive placement experiences and learning outcomes. Virtual tours augmented with cultural information further ensure that students are culturally and professionally prepared to observe appropriate health service delivery insitu. This will reduce anxiety and may be useful for other health services and education providers seeking to prepare students for placement in Aboriginal health care settings.

Key words: Aboriginal health, clinical placement, collaboration, orientation, virtual tours

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Introduction

To Close the Gap, a national strategy to reduce the disadvantage between the health of Indigenous and other Australians [1-3], has spawned a nation-wide drive to include Aboriginal health, history and culture in undergraduate health curricula [4, 5], expose more non-Indigenous students to Aboriginal communities and health services [1, 4-13], and to increase the cultural awareness, cultural safety and competence of graduates [1, 4-6, 8,11-15]. Goold and Usher [8, p.290] claim, ‘We need non-Indigenous health professionals who are better prepared to work with Indigenous people’. While health science students at the University of Tasmania (UTAS) undertook approximately 900,000 hours of workplace learning in 2015, less than 0.1% of these hours was in Aboriginal health. This paper reports on a collaborative project between the Tasmanian Aboriginal Centre (TAC) and the University, designed to prepare students for placement in Aboriginal Health Services.

Throughout Australia, the history of Aboriginal culture following colonisation has been marked by dispossession, displacement, and disadvantage [16]. In Tasmania, the situation was compounded by the speed and scale of near genocide and loss of cultural knowledge and identity [17]. In 2011, the population of Aboriginal and Torres Strait Islanders in Tasmania was 19,625 or approximately 4% of the state’s total population [2]. Although contested, these figures demonstrate there is a significant Aboriginal population in Tasmania that could provide students with meaningful Aboriginal health care experiences.

The evidence that a positive placement experience influences graduates’ career choices [18, 19] has implications for exposing students to workplace learning in areas of identified workforce need [10, 19, 20]. However, to influence career choices, students need to be enabled to make the most of their placement experience and that begins with them being appropriately prepared and supervised [19, 21]. The capacity of Aboriginal health services to support students is limited by the scale of service, staffing profile and regulatory supervision requirements [19, 22] which can be onerous for small health services [19].

A virtual tour is an online, reality-based panoramic overview of an existing place. Virtual tours are technology-mediated and can combine different media such as imagery, audio, video, text, music, maps and photography. They can be accessed online any time and be static or interactive. Though often used for marketing and travel, Virtual tours have been used in various health and higher education settings as a mechanism to realistically represent and orientate people [23-26]. The aim of the current virtual tours was to prepare students for placement in Aboriginal health services in a way that was culturally-informed, flexible, timely and effective from the perspectives of the participating Aboriginal health services and education providers.

The driver for these virtual orientation tours was the desire of the Tasmanian Aboriginal Centre (TAC), an Aboriginal Community controlled organisation, to extend its student placement profile and capability in a way that promoted cultural safety and was time and resource effective. The TAC is an affiliate of the Australian National Aboriginal Community Controlled Health Organisation (NACCHO), therefore has links with over 150 Aboriginal health services across Australia. Embracing a whole of community, whole of life worldview [9], the Aboriginal conception of health manifests in the holistic nature of Aboriginal health services which include but are not limited to:

…health promotion and disease prevention services, substance misuse, men’s and women’s health, specialised services to children and the aged, services for people with disabilities, mental health services, dental care, clinical and hospital services and those services addressing, as well as seeking the amelioration of poverty within Aboriginal communities [9, p.6).

The TAC’s role is to provide a comprehensive suite of primary health care services to individuals, families and community groups. The TAC is also a Registered Training Organisation (RTO) that offers nationally recognised Certificates in Aboriginal Primary Health Care enabling Aboriginal people to become Aboriginal Health Workers. Key personnel from the TAC approached the ‘virtual tour’ team from the UTAS Centre for Rural Health (CRH) to develop virtual orientation tours. The core business of the CRH, a University Department of Rural Health funded by the Australian Government Department of Health, includes supporting students doing rural placements and promoting rural and Indigenous health.

Methods

Ethical framework

Ethics approval for the project was granted by the Tasmanian Medical Human Research Ethics Committee (H0013548). The project was underpinned by mutual respect, inclusivity, reciprocity and commitment to Aboriginal voice and Community [1,14, 27, 28].

Design

A Participatory action approach was adopted as this aligned well with the practical and collaborative nature of the project [29]. A Participatory action approach is cyclical and iterative, simultaneously allowing action (change) and understanding and knowledge to be gained from ongoing reflective practise [29, 30]. Participatory action is ideal for promoting engagement between partnering stakeholders, working together ‘with’ rather than ‘on’, pursuing shared goals and demonstrating mutual respect [6, 31-33]. The cycle of reflection, planning, data gathering, action and evaluation (see Figure 1) is core to achieving desired outcomes, working around a situation and minimising alienation of stakeholders [29].

Figure 1: Cyclical Participatory action process

The project required active participation to define the goals and scope of the project, devise an action plan, decide virtual tour content, reflect on preliminary products and feedback, reconceptualise the product and make improvements. The virtual tours were evaluated from a realist perspective in order to establish the outcomes for whom, how and in what context [34].

Setting and participants

The project settings were three geographically dispersed Aboriginal health services in Tasmania, Australia. The project team comprised Aboriginal and non-Aboriginal health professionals working in these Aboriginal health services, staff from the TAC and academics and web-developers from the CRH. Aboriginal participants included administrative staff and two Practice Managers, (one an Aboriginal Health Worker), and an academic with a nursing background. Non-Aboriginal health professionals included two General Practitioners (GPs) and two academic nurses.

Collaboration

The TAC initiated and held carriage of the project, oversaw the approval process with community members and has ownership of the online tour product. The CRH project members contributed educational understanding related to preparing students for placement and experience developing virtual orientation tours. Cultural sensitivity was guided by the TAC project leader who had responsibility for decisions regarding cultural content and imagery, inclusion and exclusion of content, the accuracy of information about TAC services and access to cultural information given to students through its website. Engagement, accuracy and ownership was increased by enabling all affected by the virtual tours to be involved in the action (decision-making, videos, cultural and practical content) and reflection (review).

Data collection

The participatory action approach meant data were collected to inform the development of the tours and to elicit evaluative feedback. Data for the informational content, actioning of images and video-clips were gathered during face-to-face discussions at each Aboriginal Health Service (AHS). The focus was on gathering information that would give students access to useful cultural, clinical and practical information that the AHS and educators considered would add value to students’ placement.

The virtual tours were designed so students could visualise the venue, familiarise themselves with the services provided and gain some local cultural understanding. Data were collected about the layout, facilities and services, car-parking, where, when and who to present to on arrival, about organising meals and storing personal belongings. Each virtual tour included a floor plan of the building, information about the roles of key personnel and at least one welcome video message from the regional and/or practice manager, Aboriginal health worker or medical director. The multi-media structure of the virtual tours was designed somewhat like a documentary. Accordingly, information about local Aboriginal culture and history, the TAC, its services and Aboriginal health, were linked to the tours through the TAC website and its cultural information management system.

Technical aspects

Quality 360° panoramic images were required to represent the health services realistically and contextualise internal and external relationships. The panoramic views were designed to allow the viewer flexibility to explore the tour at their own pace. An ‘active’ floor plan was used to help orientate viewers and enable them to target areas of interest without having to view the whole tour. Clickable ‘information spots’, images and video data were embedded within each tour to progressively build understanding in-context. A test website was set-up for participating stakeholders to trial and review tours, provide feedback, approve content or recommend changes.

Content and data were collated and transformed into multimedia virtual orientation tours (see Fig.2). The Virtual Tours were made accessible to students from any education provider via the Tasmanian Clinical Education Network website www.tcen.com.au/virtual-tours and the TAC’s website www.tacinc.com.au.

Figure 2: Page view Entry to Virtual tour of an Aboriginal health service

Evaluation

To evaluate the functionality and utility of the online tours, data were collected by means of online testing, monitoring access metrics, project field notes, critical reflection and semi-structured discussions with key TAC and education stakeholders. In keeping with the realist evaluative perspective outlined previously, the quotes selected address the utility of the tours (what worked for whom and in what circumstances), the mechanisms (how it worked) and the outcomes for different stakeholders.

Results

The virtual tours of three Aboriginal health services were uploaded online in 2015. By May 2016, the tours had been viewed approximately 1,500 times. Aboriginal Health Service open days provided a forum for the project team to showcase the Virtual tours and interact with Community members, health care students, Aboriginal health workers and medical practitioners who viewed them. Though unable to authenticate the feedback provided at open days, the over-arching response to the tours was inherently positive. Project team members and key stakeholders also provided feedback about the mechanism and utility of the tours. From the perspective of the project team:

They [virtual tours] …provide a mechanism to promote students’ awareness of Aboriginal health, history and culture, the need to be culturally respectful and to demonstrate cultural safety. Adopting a collaborative, participatory approach has privileged local knowledge and expertise and promoted mutual respect and commitment. Rather than outsiders imposing on others, this approach enabled access to priority areas and people …to do the photography and videotaping at times most suitable to them. (PT1)

The approach facilitated the sharing of resources and ethical inclusion of culturally appropriate content approved by the Aboriginal Community. (PT2)

Online orientation tours provide students, regardless of education provider or discipline, ready online access to consistent information. The tours augment the preparation and orientation of students and provide a standardised, effective way to reduce duplication and alleviate the load on Aboriginal health service providers and faculty. (PT3)

Co-construction of content and images achieved a more valuable orientation resource for students [to prepare them for placement in an Aboriginal health service] than could have been achieved by either party in isolation. (PT4)

Aboriginal health services and faculty involved in managing undergraduate placements consider the online tours to be a valuable adjunct to orientating students about Aboriginal health and culture and value the consistency they afford. An education provider revealed that without the virtual tours it was likely that students in different disciplines would receive different information. Concern about inconsistency was echoed by an Aboriginal health service provider:

You never know and always worry about what information students are given before they arrive. They may not have been given any information about us and even when they arrive, may receive different information depending on who is here. (TAC2)

Comments related to utility:

As a registered training organisation we train Aboriginal Health Workers so the virtual tours will be of value to these students as well as those studying other health courses. (TAC1)

The virtual tours would be great for registrars who come from interstate; or have not visited the AHS, or done cultural awareness training that involved a visit to the AHS. If a registrar or a student had not had the opportunity for a visit here the virtual tours would be a fantastic resource. (Medical Registrar1)

Preparation, allaying fears and anxieties and setting the scene allow for all concerned to flourish and provide the best possible healthcare. (Education Provider1)

Overall, these results indicate from both an education and Aboriginal health service perspective, that this web-based virtual orientation initiative provided a valuable mechanism for preparing students for placement.

Discussion

The aims of this project, to augment the preparation of health science students for placement in Aboriginal health services using a co-constructed virtual web-based platform were achieved. The online tours linked to community approved cultural information provide a safe learning environment [21] and a pathway that bridges the needs of all stakeholders. Students are often daunted by undertaking placement in unfamiliar settings such as Aboriginal health and need to be suitably prepared for placement [11, 15, 19, 31]. Virtual tours provide a generationally convenient [23], flexible, resource-effective mechanism to attract and prepare non-Indigenous students to Aboriginal placements; a precursor to equipping non-Indigenous graduates to provide culturally respectful care to Indigenous people and recruiting more staff to Aboriginal Health Services [5, 8, 10, 11, 19].

Promoting cultural awareness and safety

The need to expose more students to Aboriginal health without jeopardising health service delivery to Aboriginal people makes it imperative that students are adequately culturally prepared for placement in these settings [11, 19]. This project was underpinned by elements that reflect the cultural respect framework [28] and the National Aboriginal and Torres Strait Islander Health Plan 2013-2023 [1]. A culturally safe and secure environment is defined by those who use the service [9]. In the context of health care, cultural safety requires that relationships between health professionals and Aboriginal people are appropriate, respectful and mindful of how culture and history may influence their needs and responses [3, 9, 35-37]. Student access to approved cultural information was included to promote cultural awareness and minimise the risk of racism [21]. Additionally, the links to cultural resources provide a mechanism to enhance students’ understanding of the strong link and interdependence between Aboriginal peoples’ health and connection to land, culture and community [16, 35-37].

Optimising learning outcomes

There is evidence that workplace learning is optimised when students know what to expect, feel confident, welcome, supported, and the learning environment aligns well with their expectations and learning objectives [1, 8, 38-39]. The evidence that a positive placement experience influences graduates’ career choices [18-19] also has implications for preparing students for learning in areas of identified workforce need such as Aboriginal health [10, 36]. Though the need for communication, collaboration and partnership are central to improving Aboriginal health, including Aboriginal content in health curricula and quality placements [6, 8, 10, 14, 19, 21, 32], there are relatively few examples of consultation between Aboriginals and education providers informing the preparation of students for placement [6, 8, 11].

Benefits of virtual tours and implications for Indigenous health

The co-construction of this web-based orientation platform demonstrates the value of Aboriginal placement and education providers working together to develop practical, culturally-informed learning resources that, once developed, are readily available to all students. Studies evaluating virtual tours in higher education have found that undergraduate students are comfortable with on-line learning, that the tours allay anticipatory anxiety, increase students’ engagement in an area and promote affective learning [23-25].

In the current context, virtual tours offer a solution to preparing small numbers of students for placements throughout the year. Providing people access to virtual tours can demystify health services [26], inspire interest [25-26] and begin orientation prior to arrival [26]. Virtual tours may also facilitate more appropriate delivery of health services to Aboriginal people in other settings because students who engage with the tours will be more mindful of cultural safety and less likely to unwittingly demonstrate racism, a known impediment to optimising Indigenous health and health care in Australia [40]. Virtual orientation tours could therefore become an enabler of health service provision by facilitating cultural safety in other settings and helping to recruit staff. Furthermore, virtual tours could orientate new patients to the service.

Limitations

This project was limited to one Aboriginal community controlled organisation, three Aboriginal health services, (where the majority of the state’s Aboriginal health workers practice), and one university. Evaluation is challenging for participatory action research and arguably, best suited to a realist evaluation framework [34]. The local scope of a project means that evaluative data may be limited, geared to reaching key stakeholders to establish what works for whom and under what circumstances, or captured by reflective comments of the project team and therefore subject to charges of bias. To alleviate bias, a mix of reflective and stakeholder data were reported to capture the context, mechanism and outcomes. Another limitation is the lack of the student perspective which was prevented by the project timeframe and limited use of Aboriginal placements.

Conclusion

This paper reports a collaborative initiative by an Aboriginal community controlled organisation and one Australian university to develop a web-based platform incorporating virtual orientation tours and access to cultural information to augment the preparation of health care students for placement in Aboriginal health. Online access to virtual tours of Aboriginal health services provided a consistent, timely and effective mechanism for preparing students for placement. Adopting a participatory approach that was responsive to the needs of stakeholders, resulted in a culturally-informed orientation strategy available to all students. In working together, these virtual orientation resources achieved a more valuable resource for students than could have been achieved in isolation. Furthermore, the online tours provide an ongoing mechanism for attracting and preparing students for placement in Aboriginal health and potentially, recruiting staff. Though these tours are unique, the ideas and collaborative process may be useful to similar organisations and education providers seeking to close the health gap by attracting more non-Indigenous students to placement in Aboriginal health. The rapport and goodwill generated augur well for future collaboration.

References

1. Australian Government. National Aboriginal and Torres Strait Islander Health Plan 2013-2023. 2013. Retrieved 05 November 2015 from: http://www.health.gov.au/internet/main/publishing.nsf/content/B92E980680486C3BCA257BF0001BAF01/$File/health-plan.pdf
2. Australian Bureau of Statistics. 2012. Census of population and housing – Counts of Aboriginal and Torres Strait Islander Australians 2011. Canberra: ABS
3. Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples 2015. Cat. no. IHW 147. Canberra: AIHW.
4. Australian Medical Council 2012. Standards for assessment and accreditation of primary medical programs. Retrieved 06 November 2015 from: amc.org.au/accredtitation/primary-medical-education
5. Australian Nursing & Midwifery Accreditation Council 2012. Accreditation standards – Entry program registered nurses. Retrieved 16 November 2015 from: http://www.anmac.org.au/sites/default/files/documents/ANMAC_RN_Accreditation_Standards_2012.pdf
6. Andersen C. Indigenous footprints on health curriculum. The Australian Journal of Indigenous Education. 2009; 38: Supplement 40-45.
7. Brazen JJ, Kruger E, Dyson K, and Tennant M. An innovation in Australian dental education: rural, remote and Indigenous pre-graduation placements. Rural and Remote Health, 2007; 7: 703 (Online). Retrieved from http://www.rrh.org.au
8. Goold SS, and Usher K. Meeting the health needs of Indigenous people: How is nursing education meeting the challenge? Contemporary Nurse, 2006; 22(2); 288-295.
9. NACCHO 2011. Constitution for the National Aboriginal Community Controlled Health Organisation. Retrieved 16 November 2015 from http://www.naccho.org.au/download/naccho-governance/NACCHO%20CONSTITUTION%20Ratified%20Ver%20151111%20for%20ASIC%20.pdf
10. Mason J. 2013. Review of Australian Government Health Workforce Programs. Retrieved 18 October 2014 from http://www.naccho.org.au/download/training/Review%20of%20Health%20Workforce%20programs.pdf
11. Nash R, Meiklejohn B, and Sacre S. The Yapunyah project: Embedding Aboriginal and Torres Strait Islander perspectives in the nursing curriculum, Contemporary Nurse, 2006; 22(2); 296-316.
12. Paul D, Carr S, and Milroy H. Making a difference: the early impact of an Aboriginal health undergraduate medical curriculum. Medical Journal of Australia, 2006; 184(10); 522-525.
13. Paul D, Allen C, and Edgill P. Turning the corner Assessment: a key strategy to engagement and understanding in Indigenous health. Focus on Health Professional Education: A Multi-Disciplinary Journal. 2011; 13(1); 52-64.
14. Australian Government Department of Health and Ageing, 2007. National Strategic Framework for Aboriginal and Torres Strait Islander Health: Implementation plan 2007-2013.
15. Durey A. Reducing racism in Aboriginal health care in Australia: where does cultural education fit? Australian and New Zealand Journal of Public Health, 2010; 34, S1:87-92.
16. Muller L. 2014. A theory for Indigenous Australian health and human service work: Connecting Indigenous knowledge and practice. Allen & Unwin: Sydney.
17. Boyce, J. 2008. Van Diemen’s land. Black Inc. Melbourne.
18. Lea J, Cruickshank M, Paliadelis P, Parmenter G, et al. The lure of the bush: Do rural placements influence student nurses to seek employment in rural settings? Collegian, 2008; 15(2); 77-82.
19. Webster S, Lopez V, Allnut J, Clague L, et al. Undergraduate nursing students’ experiences in a rural clinical placement. Australian Journal of Rural Health, 2010; 18, 194-198.
20. Health Workforce Australia. A framework for effective clinical placements in rural and remote primary care settings. 2013. Health Workforce Australia: Adelaide.
21. Jacob E, Raymond A, Jones J, Jacob A, et al. Exploration of nursing degree students’ content expectations of a dedicated Indigenous health unit. In Press, Collegian. 2016; 23(3), 313-319.
22. Australian Nursing & Midwifery Accreditation Council. 2012. Registered Nurse Accreditation Standards. Canberra, Australia: Australian Nursing & Midwifery Accreditation Council.
23. Ariffin AH, and Talib, AZ. User acceptance of panoramic views as a technique for virtual tours in an educational environment. Informatics Engineering and Information Science, 2011; 252, 117-127.
24. Hookham G, Nesbitt K, Cooper J, and Rasiah R. Developing a virtual tour of a community pharmacy for use in education. IT in Industry, 2014; 2(1), 33-37, ISSN: 2203-1731.
25. Burhanna KJ, Voelker TJ, and Gedeon, JA. Virtually the same: Comparing the effectiveness of online versus in-person library tours. Public Services Quarterly. 2009; 4(4): 317-338.
26. Lau W-C, Choi K-S, and Chung W-Y. A Virtual Psychiatric Ward for Orientating Patients Admitted for the First Time. Cyberpsychology, Behavior and Social Networking. December 2010; 13(6): 637-648.
27. NH&MRC. (2004). Values & ethics: Guidelines for ethical conduct in Aboriginal & Torres Strait Islander health research. National Health & Medical Research Council. Canberra, ACT: Commonwealth of Australia. Retrieved 19 February 2015 from https//www.nhmrc.gov.au/_files_nhmrc/publications/attachments/e52.pdf
28. Australian Health Ministers Advisory Committee (AHMAC). 2004. Cultural respect framework for Aboriginal and Torres Strait Islander Health 2004-2009. ISBN 0 7308 9351 0.
29. Baum F, MacDougall C, and Smith D. Journal of Epidemiological Community Health, 2004; 60(10); 854-857.
30. Kemmis S, McTaggart R, Communicative action and the public sphere. Denzin, NK & Lincoln, YS (Eds.). The Sage handbook of qualitative research. 2005; 3:559-603.
31. Henderson R, Simmons DS, Bourke L, and Muir J. Development of guidelines for non-Indigenous people undertaking research among the Indigenous population of north-east Victoria. Medical Journal of Australia, 2002; 176: 482-485.
32. Hunt J. Engaging with Indigenous Australia: Exploring the conditions for effective relationships with Aboriginal and Torres Strait Islander Communities. 2013. Closing the Gap Clearinghouse. Retrieved 16 November 2015 from http://www.aihw.gov.au/uploadedFiles/ClosingTheGap/Content/Publications/2013/ctgc-ip5.pdf
33. Elston JK, Saunders V, Hayes B, Bainbridge R, and McCoy B. Building Indigenous Australian research capacity, Contemporary Nurse. 2013; 46(1): 6–12.
34. Greenhalgh T, Wong G, Jagosh J, Greenhalgh J, et al. BMJ Open protocol- RAMESES 11 study: developing guidance and reporting standards for realist evaluation. BMJ Open. 2015; 5:e008567.
35. Eckermann A-K, Dowd T, Chong E, Nixon L, et al. 2010. Binan Goonj: Bridging cultures in Aboriginal health, 3^rd Churchill Livingstone: Sydney.
36. Australian Human Rights Commission 2011, Close the Gap: Indigenous health campaign 4.2. Retrieved 16 November 2015 from https://www.humanrights.gov.au/close-gap-indigenous-health-campaign
37. Health Workforce Australia. Reconciliation action plan. 2013; HWA13CF001.ISBN 978-0-9874701-1-9.
38. Henderson A, Twentyman M, Eaton E, Creedy D, et al. Creating supportive clinical learning environments: an intervention study. Journal of Clinical Nursing, 2010; 19(1-2): 177-182.
39. Levitt-Jones T, Lathlean J, Maguire J, and McMillan M. Belongingness: A critique of the concept and implications for nursing education. Nurse Education Today, 2007; 27(3); 210-218.
40. Awofeso N. Racism: a major impediment to optimal Indigenous health and health care in Australia. Australian Indigenous HealthBulletin. 2011; 11(3).