taking control of health: gurriny's story of

TAKING CONTROL OF HEALTH: GURRINY'S STORY OF ORGANISATIONAL CHANGE Janya McCafman, School of Education, Cairns Institute, James Cook University; Komia Tsey, Schoof of Education, Cairns Institute, James Cook University; Lyndon Reilly, Collaborative Research on Empowerment and Wellbeing, School of Medic ine, University of Queensland; Brian Connolly, Soc ial and Emotional Wellbeing Unit, Gurriny Yealamucka Health Service; Ruth Fagan, Planning and Partnerships Unit, Gurriny Yealamucka Health Service; Wendy Earles, School of Arts and Social Sciences, Cairns Institute, James Cook University; and Ross Andrews, Social and Emotional Wellbeing Unit, Gurriny YeaJamucka Health Service

ABSTRACT

This case study provides a detailed analysis of olle change process withill al/ Aboriginal community-coli/roiled health organisation. It was based On a process of reflective action research to inform ongoing service-deveJopmel/l alld quality-improvemem through an established working partnership with university researchers. The focus was strengthening the origillal social and elllotional weil-being services and striking a balallce between biomedical dominance versus the promotion of social alld emotional well-being. The result was a model of empowermel/l processes and outcomes to guide organisational change and a range of benefits for the organisation. The study provides all example for others interested ill similar processes alld identifies some of the key success factors for community cO/lfml. KEYWORDS: Aboriginal community control; organisational change; empowerment; social and emotional wcll-being; knowledge transfer; hcalth. INTRODUCTION As part of their I struggle for self-determination s ince the early 1970s, Australian Aboriginal people have built more than 130 non-profit communitycontrolled health organisations across Australia (NACCHO 2006). They are initiated by Aboriginal people, governed by elected Aboriginal boards and provide a service-delivery model that is complementary to mainstream health organisations. Since they are embedded within the Aboriginal cultural domain, they can often better engage Aboriginal community members, provide access to services and promote leadership opportunities. They can therefore be seen as a health intervention in their own right (Coombe 2008). This accords with recent international evidence thai movements by disenfranchised individuals and groups to effectively advocate for their own Third Sec/()r Re view. Volume 16, No. I

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interests, and thereby ehallenge the unfair distribution of soeial resourees, play an im portant role in improving health outcomes, quality of life and health equity (Wallerstein 2006; Commission on Social Dcterminants of Health 2008). Aboriginal community-controlled health organisations aim to deli vcr holistic and culturally appropriate health services (NACC HO 2006). In contrast to the Western biomedical paradigm, which is based on the treatment of various body parts or diseases, the Aboriginal concept of health is based on the physical, social, emotional and cultural wcll-being of the whole community, in which each individual is able 10 achieve their full potcntial as a human being. This whole-of-life view includes the cyclical concept of life-death- life (NACCHO 2006). In practice, both biomedical (clinical) and/or social and emotional well-being (SEWS) services arc provided. SEW S rcfers to: the emotional and p~}'chological aspects of child and adult development as weil as the importance and nature of the social and community relationships supporting good health. Key factors in achieving this include connectedness to family and community. control over one s environment and exercising power of choice. (Zubrick et a1. 2005) Given the paucity of empirical literature about Aboriginal organisational change (Earles 2007; Coombe 2008), it has been challenging for Aboriginal leaders to know where to start and how to implement service-delivcry improvements. These processes require meeting the compl ex health needs and interests of their constituent communities, drawing upon the valucs and ex periences of their Aboriginal staff in order to improve organisational efficiencies, and strategically cngaging with the formal and informal institutions of the dominant Australian society. Often this involves engaging in processes that challenge thc status quo in order 10 improvc the (poor) health status of their people (Coombe 2008). Ideally, these processes result in an organi sational culture of learn ing, 'towards which organisations have 10 evolve in order to be able to respond to the various pressures [they face]' (Finger & Srand 1999: 136). Recent research on Aboriginal and mainstream health and welfare organisations has found that, despite ongoing structural constraints, the usc of empowennent processes has resulted in improvements in organisational effectiveness. Thi s has occurred through improved sta ff engagement, leadership and communication in the workplace, and an increased willingness by management to respond to the needs of a more confident and assertive workforce (Whiteside et aL 2006; McEwan e\ a1. 2009). Empowerment 30

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processes have also enhanced the health and well-being of Aboriginal staff by making their ex perience of change more understandable as part of a bigger picture, and by providing them with opportunities 10 reflect on their lives, future goals, and potential as individuals and agents in the process of organisational and community change (Whiteside et al. 2006; McEwan et al. 2009). This paper documents a case study of the organisational-change processes in one Aboriginal non-profit community-controlled health organisation. Gurriny Yealamueka (pronounced Gerr-rin-ee Yell-a-mllck-a) Health Service (hereafier rcfeITed to as 'Gurriny') is located in Yarrabah, a coastal Aboriginal community of 3000 residents in northern Queensland. At the start of this rcsearch process in October 2007, Gurriny had been operating for almost ten years. It had 12 local Aboriginal board members, four local Aboriginal managcrs and a staff of 15 (13 of whom were local Aboriginal people). The service had started by providing SEWS serv ices, including men's group, womcn's group and youth group programs, and had just started to incorporate health-promotion and biomcdical services. This paper results from GUITiny's dceision 10 draw on its established working partnership with university researchers to document its journey in becoming a comprehensive primary-care service, and particularly its efforts to strike a balance between biomedical dominance and SEWS promotion. It describes a process of reflective action research with Gurriny managers and SEWS staff to inform the ongoing service-development and quality-improvement of its SEWS services, and the potential for adapting the learning outcomes from the SEWS team's empowerment processes to its broader processes of change. Empowerment is defined as 'a process by which individuals, groups and communities gain increased control over their lives' (Wallerstein 2006). We start with a brief background of the Yarrabah context and the phases of Gurriny's organisational development. COLONIAL HISTORY AND THE EVOLUTION OF YARRABAH AS A COMMUNITY

The traditional custodians of Yarrabah are the Gunggandji and Yidinji peoples, but they currcntly comprise only 20% of residents. More than 75% of residents arc descendants of families who were forcibly removed to the area under the Aboriginals Protection and Restriction of the Sale of Opium Act of 1897 as part of the 'stolen generations'] and brought to the mission by government and church agencies. As a result, the descendants of approximately 40 different language groups live in Yarrabah. Only 3% of residents arc non- Indigenous (ASS 2007).1 Third SeeMr Review. Volume 16, No. I

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Figure 1 - Yarra bah Although Yarrabah is just 'over the hill' from Cairns, it was recently ranked as Queensland's most disadvantaged local government area based on income, job status, occupation, personal qualifications, service availability and housing conditions (ABS 2008). Only one in five adults have fulltime employment, family incomes are 55% of the Australian median, and the housing occupancy rate is up to II persons per dwelling (ABS 2007). Despite alcohol restrictions placed on residents (ATSIP 2009),4 substance misuse and associated violence and chronic disease are significant problems. Government reports state that, per capita, Yarrabah had almost ten times more offences against the person (January- March 2009), three times more diabetes and five times more heart disease than the Queensland rates (Tropical Population Health Unit Network 2008; ATSIP 2009). Related to these factors , between 1983 and 1996, Yarrabah experienced three tragic waves of suicides, with 22 deaths and many recurrent incidents of suicidal behaviour. Phase One: From crisis to community mobilisafion to achieve health (1998- 2001 ) Following periods of church (1892- 1960) and state government control , Yarrabah became a self-governing community in 1986. Shortly afterwards, a proposed health-care plan (in 1988) found that state and local government health organisations were fragmented and had no local control, use of local skills or commitment to training. Community people were reluctant to use the doctor, attendance at the antenatal clinic was poor, and primary healthcare principles were not being employed (H unter et al. 200 I) . Ln the context of the suicide crises of the 1980s and 90s, Yarrabah Council, in partnershi p with the University of Queensland, initiated a feasibility study 32

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for a new multipurpose health-care service. Residents consulted described needs for 'reclaiming spirit', 'responding to the experience of hopelessness', 'loss of land, loss of spirit, loss of culture, hurt, pain , intergenerational trauma and unresolved grief and trauma, recent and past' (Baird et al. 1998) (see Figure 2). ~1II\INreJ,tj~fo'

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Figure 2 - Factors identified in the feasibility study as being related to poor health and wellbeing in Yarra bah Source: lJaird et al. (1998)

A strategic decision was made by Yarrabah Council in 1998 to establish the 'Yarrabah Health Council' to conduct preventive health-care programs primarily for rheumatic fever, hearing health, diabetes and suicide (GY HS 2008) . In 2001 the service was renamed Gurriny Yealamueka ('good healing water'), in reference to a sacred Gunggandji healing site. The organisation was incorporated and a governing committee of 12 Yarrabah Aboriginal people was clected. In addition, the council closed the alcohol canteen, obtained funding for two life-promotion officer positions and supported the establishment of a voluntary men's group. Phase Two: Gurriny- university collaboration to develop a social and emotional well-being program (200J - 2005) Faced with the problem that government medical services were readily available in Yarrabah and yet residents' health needs were not being met, the governing committee and manager realised that they needed to build credibility to gain both the confidence of the community as wcll as the necessary resources. As a new organisation with two staff, they made a Third Sec/()r Review. Volume 16, No.1

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strategic decision not to challenge the entrenched government biomedical service-provider by attempting to provide competing clinical services. Instead, as recommended by the feasibility study, they focused on the community-identified gap of SEWB, aiming to become a ' Socio-Emotional and Spiritual Wellbeing Centre of Excellence to com plement eXlstlllg Queensland Health clinical services' (Baird et al. 1998). Gurriny obtained short-term funding to support the Yaba Bimbie (,Father! Son ' ) Men's Grou p and invited a researcher from the University of Queensland (author KT) to a men's group meeting. Keen to assess Yarrabah men's interest in using empowerment processes, the researcher introduced a topic from the Aboriginal-developed Farnily Wellbeing (FWB) empowennent program to the men. The FWB program had been developed in 1993 by Adelaide-based Aboriginal community leaders, who (like many YalTabah residents) had been directly affected by the 'stolen generations' policies. It aimed to build communication, problem-solving, conflict-resolution and other necessary sk11ls and thus enable individuals to take greater control and responsibility for their family, work and community life ( Daly et al. 2004). Yarrabah men's group leaders responded enthusiastically and so researchers delivered the 30-hour first stage of FWB to the men's group (and later to the women ' s group, the alcohol-rehabilitation service and the youth crime-prevention program). Reflective FWB and participatory action research (PAR) processes became foundational strategies for the SEWB programs. These programs built trust and confidence, not only amongst participants of the groups, but also with researchers. FWB was subsequently delivered by Gurriny SEWB staff to community men's and women's groups, parenting groups, alcohol-rehabilitation clients, disengaged youth and school students.

Phase Three: Towards a comprehensive primary health-care communitycontrolled service (2005-2007) By 2005, the research partnership had produced a series of peer-reviewed papers and reports, which contributed to the cmerging body of knowledge on practical ways to operationalise S EWB in health-program delivery, thus positioning Gurriny as a leader in the field (Tsey et al. 2002, 2004a, 2004b; Daly et al. 2004). This contributed to significant funding for the organisation and expansion of the SEWB workforce, including recurrent funding for four staff from the Commonwealth Department of Health and Ageing from 2007. Services included men's group, men's cultural dance, women 's health, childcare links and youth crime-prevention programs.

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In 2005 the Gurriny CEO signed a 'Deed of Commitment' with the Commonwealth and state governments for the staged transition of planning and management for a full range of biomedieal services in addition to its SEWS serviees. It was agreed that Queensland Health would retain eontrol of elinieal services at the Yarrabah hospital, but a number of state-managed primary health-care services would be transferred to Gurriny, along with funding, workforce, capacity-building and infrastruetural resources. The commitment also encompassed Gurriny's relocation to joint premises within a proposed multi-million-dollar health-service complex. As Gurriny entered a phase of rapid growth, managers recognised that there was a danger that the original core of SEWS services could become increasingly marginalised within the organisation. A number of factors had created a sense of uneenainly for the SEWS staff, lack of elarity about their role within Gurriny, high levels of stress and poor morale and productivity. These ineluded the relocation of the team to a building at some distance from the main Gurriny office, a lack of funding for extended periods for a team manager, a lack of clarity about lines of authority and management ex pectations, and budgeting complexity. In addition to workplace stressors, SEWS staff members were also subject to the same stressors as the wider Aboriginal community and were experiencing SEWS issues themselves. Gurriny management responded with attempts to increase the teams' accountability ,md to provide greater supervision and support through the appointment of a (shon-ternl) social-health manager. They also recognised the importance of research support. In October 2007, managers (including authors RF, RA and SC) invited university researchers (JMc and KT) to extend their previous PAR processes to the SEWS team, with the aim of addressing the issues that had arisen through the organisational-change processes. METHODS

Knowledge associated with organisational innovation is often informal, context-dependent and embodied as practical wisdom in the person/s or organisation that has it. Therefore, it is not an easy area to research empirically, especially in a field of overlapping Aboriginal and Western academic ontologies. It involves detailed documentation of particular microprocesses or events, and is dependent for its meaning on interpretation and negotiation by individuals in a particular context (Greenhalgh et a!. 2005). This research process aimed to support the managers and SEWS staff of Gurriny to take greater charge of their processes of organisational change by drawing on the practical knowledge and experience of SEWS staff, towards

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both the further devclopment of SEWB servi ces, and potential adaptation and incorporation within Gurriny's broader organisational structures and processes. It draws on the theoretical position of empowerment, aiming to analyse and interpret the status of values and interests within the organisation, with the intention of providing social commentary and social action, i.c. praxis (Flyvbjcrg 2001). At thc direction of the Gurriny managers, thc rescareh started by building on the previous PAR processes with thc SEWB stafT. Given the low morale of thc tcam, an apprcciative-inquiry framework was chosen because of its focus on extending and elevating existing strcngths, finding solution s to problems, and appreciating and capitalising on what was already working well (Boyd & Bright 2007). As depicted in Figure 3, the appreciative-inquiry proccss involved a cyclical proccss of opportunity-centred change, using the ' 4-D' framcwork: di scover, dream, design and destiny. Researchers from James Cook University (JCU) and the University of Queensland (UQ) - a non-Indigenous woman, JMe, and an Aboriginal man, LR - facilitated 14 sessions with the cight Gurriny SEWB stafT from March to October 2008. The sessions were documented by both facilitators, with notcs being compared, written up and provided back to stafT at the next session. Thcse 'minutes' were coded and categorised, us ing standard processes of thematic analysis. The findings were also presented to Gurriny managers.

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",,- - added rich 'voice' to the somewhat mechanistic themes that emerged from the synthesis. To complete the 'discover' phase, the SEWS staff brainstormed 20 critical SEWS issues to be addressed as priorities in Yarrabah. Following discussion, they agreed that the fundamental problem was abuse. 'We all suffer from abuse as a result of historical processes ... it is a huge issue and we need to identify skills on how to motivate each other in the team.' The SEWS team identified further strengths of their programs. The common denominators underlying all SEWB programs were identified as the FWS program, the 'dos and don ' ts ' values list, court support, cultural development and health checks. They reflected that their capacity to 'identify new needs through existing programs' had prompted the expansion of the SEWS programs

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- examples were the youth group, eultural dance and cultural-development projects that had developed in response to men ' s group concerns.

Dream The dream phase aimed 10 define a vision for the SEWB team as a whole, building on the strengths identified in the prev ious phase. A new vision statement for the team was developed: 'To empower people through education 10 reduce the high rates of abuse.' Abuse was defined broadly to include physical, sexual , emotional and verbal abuse. Staff said that the FWB program could provide the basis for a shift in focus from men 's and women 's group programs towards collaboration as a team, in order to address family dysfunction. They expressed a commitment to 'promoting and supporting one another' and to continuing the process of eapaeity·strengthening across the team, ineluding supporting new positions, obtaining counselling and healthpromotion qualifications, and improving work performance. Staff reflected that they also needed to take greater responsibility for their own personal issues: 'We have to fix ourselves up first, clean our own backyard.' They also said they wished to continue to support university research projects, with one team member stating that university researchers 'arc the ones that put us on a straight track in the first place, and every time we go ofT track, they [are] there for us' . The SEWB team felt that they could also contribute in three ways to the broader Gurriny process of organisational change. Better integration of services and the development of referral systems both internally and externally from agencies and community members was considered a priority, given the recent incorporation of clinical services within Gurriny. One staff member suggested that the SEWB team was 'professional with our own people - how we talk to them. Nothing clinical or anything. We' re professional in doing things our way.' But that the team needed pathways for referral for services, like ' proper counselling'. Lmproving senior managers' understanding of what SEWB service-provision involved - for example, by providing FWB for Gurriny managers - was also considered a priority. Staff reflected that there had been confusion about the roles of SEWB staff, and consequently management sometimes had unrealistic expectations. Shortly after the research commenced, there had been three suicides in Yarrabah. The crises personally affected many Gurriny staff and led to staff absences and discontinuation of programs. Team members who were helping community members deal with these crises spoke of the stresses and flexibility required in providing SEWB • servIces:

4Q

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it keeps me awake at night . .. when I go home from work. my head goes into overtime thinking about the cOl/III/unity. It~, getting worse. Respect has gone out of the cOllllllunity. Before, an Elder had the right to correct a youllg child. Now they can't correct anybody because they can calise a big family fight.

Staff suggested that clarifieation was needed about whether 'social-health staff are counsellors or run programs', Encouraging Gurriny's original holistic approach, which incorporates spiritual and cultural values, was the third priority identified. The SEW B staff suggested that in undertaking the shift towards the provision of comprehensive health services, Gurriny had lost its original vision, or 'they may have a new focus but if so, th ey need to share it with the social-health team'. In late May 2008, the findings from these first two phases were presented (by JMe and BC) to a GUITiny managers' meeting, The aim was to report on issues raised and assess how they might contribute towards Gurriny's further organisational development towards its vision of 'lead[ing] the way in improved health outcomes' (Gurriny Bu siness Plan 2007). The presentation prompted vigorous debate, with managers eonfinning that they did not have a clear understanding of SEW B, the roles of SEWB staff or the programs being provided. Hence, one manager ex pressed concern about accountability, eompl ianee with GUITiny procedures and a lack of credibility with referring service-providers, while another saw the SEWB staff as 'the experts around social health within GUITiny'. Design The intention of the design phase was to put the learning outcomes from the two previous phases into action. Gurriny managers reflected that PAR/appreciati ve-inquiry processes could potentially be used at three levels to progress GUITiny 's health-refonn agenda: 1) to continue to build the eapaeity of the SEW B team; 2) to improve internal organisational processes; and 3) with Queensland Health and other partners to faeilitate the transitioning of services to community control by Gurriny. In particular, continuing the process with the SEWS team and internal organisational issues were considered a priority, since there were outstanding planning, pcrfonnancc and resourcing issues, and a perception that the research could assist with building the capacity of the Social Health Manager. Managers agreed that internal cOllullunication and accountability processes would be

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improved by co-locating the Social Health Manager with his team. They also agreed to implement a planning workshop with the SEWB staff, in order to develop an overarehing SEWB plan that would feed into a revised Gurriny Business Plan. In a cyclical process, the managers' feedback was provided back to the SEWS team for further reflection and development, and also used to develop a preliminary model of community control ofGurriny by Yarrabah residents. The SEWB team then embarked on a process of developing action plans for the SEWB programs, with the intention of informing the broader Gurriny business plan from the bottom up. However, in practice, the planning process was resouree- and time-intensive. It was challenging for staff to develop action plans with appropriate aims, objectives and strategies that I) incorporated the learning outcomes from the appreciative inquiry process; 2) were consistent with the Gurriny Business Plan and management expectations; and 3) considered the need for response to the varied nature of eonU11Unily requests and expectations. In the absence of funding for the process, it was agreed that the role of university researchers should be 10 assist the Gurriny staff to identify the issues and discuss options/solutions. It should be a Gurriny responsibility to action them. This left a gap, as neither the university researchers nor the Gurriny managers were able to adequately mentor staff through to the completion of detailed plans. For the researchers, the process demonstrated the importance of clearly defining roles and responsibilities at the outset of the process, particularly in relation to the 'action' component of action research. Destiny The final phase of the process involved deploying the learning outcomes from the process in order to create change. Researchers presented a summary of findings from the 4-0 process to the SEWS staff. The outstanding critical issues were identified as a prompt for the SEWS staff to consider priorities and ways forward and for presentation to the Gurriny managers. Key issues included I) the need to complete a five-year SEWB plan, including protocols for crisis management; 2) the development of a case-management system, with referral processes to complement group programs; 3) the need for clear and consistent management expectations; 4) improved budgetary control; 5) funding to employ professional male and female counsellors and/or family therapists; 6) consistent and coordinated FWS program delivery by men's and women's groups; 7) building the credibility of SEWS programs; 8) mentoring for SEWS staff; 9) orientation processes for new staff; and 10) submission/s for further funding. Staff also reflected on how 42

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they could monitor activities, know whether their programs were effective and develop a self-improving system by building assessable indicators into their action plans. To complete the process, the findings from the synthesis and appreciativeinquiry process were analysed to develop a preliminary model of community control for Yarrabah (sec Figure 4). This was presented to the SEWB team, who said that it 'makes sense - it shows how we're taking steps, linked up and all come back around'. It was also published in Gurriny's Annual Report for 2007- 08 as a model to authentically develop its organisational processes and service-delivery based on 'bottom-up' and locally defined values and principles. ..-..

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