Working in Indigenous primary health care: a continuous, interconnected and multifaceted journey for health professionals Robyn Lynette Williams BA, RN, Grad Dip Ed, MPRET Thesis submitted in complete fulfilment of the requirements for the degree of Doctor of Philosophy College of Health and Human Sciences Charles Darwin University Darwin, Australia November 2019 TABLE OF CONTENTS List of Tables .............................................................................................. iv List of Figures ............................................................................................. iv Declaration .......................................................................................................................... v Abstract .............................................................................................................................. vi Acknowledgements ........................................................................................................... vii Terminology ........................................................................................................................ ix Glossary .............................................................................................................................. xi Chapter 1: Introduction .............................................................................. 1 Introduction ......................................................................................................................... 1 Framing the topic ..................................................................................................................... 1 Importance of this study ......................................................................................................... 2 Description of the study ........................................................................................................... 3 My story – locating myself in the study .................................................................................... 3 Structure of the thesis .......................................................................................................... 7 Chapter Two: Rationale and background to the study .............................................................. 7 Chapter Three: Literature review ............................................................................................ 9 Chapter Four: Methodology ................................................................................................... 10 Chapter Five: Findings ............................................................................................................ 11 Chapter Six: Discussion .......................................................................................................... 13 Chapter Seven: Conclusion .................................................................................................... 14 Chapter 2: Rationale for the study and background ..................................... 15 Introduction ....................................................................................................................... 15 Rationale ............................................................................................................................ 15 Background ........................................................................................................................ 16 Indigenous population, health status and issues ..................................................................... 17 Concepts of health: identity, culture, belonging ..................................................................... 21 The impact of colonisation Indigenous health ........................................................................ 25 Policies .................................................................................................................................. 27 Capacity building and resilience for the Indigenous primary health care workforce ................ 32 Philosophies informing Indigenous health and service delivery models ............................... 33 Primary health care ................................................................................................................ 33 Aboriginal community controlled health organisations (ACCHOs) ......................................... 35 Indigenous health professionals ............................................................................................. 39 Working in ABoriginal community controlled health organisations ........................................ 41 Chapter summary .............................................................................................................. 42 i Chapter 3: Literature review ...................................................................... 45 Introduction ....................................................................................................................... 45 Rationale for using a literature review in a Grounded Theory study ........................................ 46 The Literature Search ......................................................................................................... 48 What the literature addresses – an overview .......................................................................... 50 What the literature does not address – an overview ............................................................... 51 Four key areas of literature .................................................................................................. 53 Profile of effective practitioners ............................................................................................. 53 Education (undergraduate, graduate, professional development) ......................................... 58 Working in Indigenous primary health care contexts .............................................................. 70 Effective and culturally safe practice ...................................................................................... 76 Chapter summary .............................................................................................................. 94 Chapter 4: Methodology ........................................................................... 95 Introduction ....................................................................................................................... 95 Social position and standpoint ........................................................................................... 96 Social position ....................................................................................................................... 96 Standpoint ............................................................................................................................ 99 Epistemological perspective: symbolic interactionism and social constructionism. ........... 100 Grounded Theory approaches .......................................................................................... 104 Overview/definition of Grounded Theory ............................................................................. 104 Outline of Grounded Theory as a methodology ................................................................... 106 Constructivist Grounded Theory .......................................................................................... 107 Why Constructivist Grounded Theory? ................................................................................ 109 Methods ........................................................................................................................... 109 Sampling ............................................................................................................................. 109 Data gathering .................................................................................................................... 112 Process of Data Analysis ................................................................................................... 114 Coding – initial, focused and thematic analysis .................................................................... 115 Ethical implications ........................................................................................................... 117 Research rigour (trustworthiness, crediBility, validity, transferaBility, limitations) ............... 120 Transferability or applicability ........................................................................................... 123 Limitations ........................................................................................................................ 123 Chapter summary ............................................................................................................. 124 Chapter 5: Findings ................................................................................. 125 Introduction ...................................................................................................................... 125 A brief description of the participants .............................................................................. 126 Themes and sub-themes ................................................................................................... 130 Theme One: Foundations of effective practitioners ............................................................. 130 Theme Two: Education 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