Exploring the role of cultural support workers in the New Zealand healthcare setting

INTRODUCTION: The introduction of the community health worker (CHW), or cultural support worker (CSW) as they are more commonly known in Aotearoa New Zealand, is being increasingly seen as an effective strategy to engage with migrant communities and improve health outcomes. With specific cultural knowledge and understanding, CSWs act as a bridge between their ethnic community and healthcare services to improve cross-cultural interactions in the healthcare setting. As Aotearoa New Zealand becomes increasingly ethnically and linguistically diverse, the use of CSWs will become an integral part of the delivery of healthcare services. However, very little is currently known about the needs of these workers – the challenges of the role; their needs for appropriate training, support and supervision; and, how

The effects of globalisation have had a significant impact on the delivery of healthcare services both here in New Zealand and overseas, with service providers now required to deliver services to increasingly ethnically and linguistically diverse communities (Crawley, Marshall, Lo, & Koenig, 2002).As healthcare providers also become more ethnically diverse, healthcare interactions require a greater level of skill and cultural understanding (Crawley et al., 2002;Kagawa-Singer & Blackhall, 2001).
Healthcare providers have met this challenge with a range of innovations including the use of cultural support workers (CSWs), to access underserved patients (Dohan & Schrag, 2005).While the use of CSWs, or CHWs as they are also known, is seen as an effective strategy to engage with ethnic minority communities and to improve access to services and health outcomes, very little is known about the challenges of, and potential for, the role, resulting in poor understanding and underutilisation of the role (Dohan & Schrag, 2005).

QUALITATIVE RESEARCH
While the use of CSWs is a relatively recent innovation in Aotearoa New Zealand, such roles have been a part of the healthcare environment in North America for many decades (Nemcek & Sabatier, 2003).Established in North America in the 1960s as a strategy to reduce health inequalities and improve access to cancer treatment services for minority communities, the CSW role has proved to be an effective development and is seen as an integral part of the delivery of healthcare services to ethnic minority populations (Alvillar, Quinlan, Rush, & Dudley, 2011;Dohan & Schrag, 2005;Love, Gardner, & Legion, 1997;Nguyen & Kagawa-Singer, 2008;Rosenthal, Wiggins, Ingram, Mayfield-Johnson, & De Zapien, 2011;Sherwen, Schwolsky-Fitch, Rodriquez, Horta, & Lopez, 2007;Wells et al., 2008;Witmer, Seifer, Finocchio, Leslie, & O'Neil, 1995).
In the USA, CSWs are now being employed in a diverse range of healthcare settings, from homes to community clinics, schools and hospitals, and are undertaking a range of different tasks (Perez, Findley, Mejia, & Martinez, 2006).The proliferation of community health worker and health navigator programmes has now focused attention on a need to gain a better understanding of their role in reducing health disparities, their training and professional development opportunities, and the way in which these workers can gain greater acceptance in the healthcare workforce (Nemcek & Sabatier, 2003;O'Brien, Squires, Bixby, & Larson, 2009;Rosenthal et al., 2011).

Context
Changes to Aotearoa New Zealand's immigration laws over the past two decades have seen dramatic demographic changes, with our largest city, Auckland, now being described as "superdiverse" (Chen, 2015).In the 2013 census, almost 50% of Auckland's population identified as Ma ¯ori, Asian or Pacific peoples, with over one third (40% of the population), not born in Aotearoa New Zealand.Auckland is now home to over 200 ethnicities and with more than 160 languages being spoken, superdiversity is the new reality (Walker, 2014).
In Auckland, the growth of CALD communities has presented significant challenges for healthcare providers.CALD is the term used to describe culturally and linguistically diverse populations from Asian, Middle Eastern, Latin American and African backgrounds (Lim & Mortensen, 2013).
As workforce diversity also increases, so does the frequency of cross-cultural interactions (Lawrence & Kearns, 2005;Mortensen, Latimer, & Yusuf, 2014).The introduction of CSWs into the healthcare setting is seen as an effective strategy to engage with CALD communities, to identify barriers and to improve access to, and the delivery of, healthcare services (Mortensen et al., 2014).
The databases searched for this study included the Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus with Full Text, Scopus, Medline, Web of Science and Google Scholar.Initial keywords used in various combinations were: community health worker; cultural case worker (in) healthcare; support (for) cultural support workers; patient navigation; personal support; job satisfaction and challenges; training needs; and education programmes.
While much of the international literature reviewed focuses on describing the CHW role and its impact on improving access to health care, there was evidence of a growing interest in evaluating training programmes and gaining a better understanding of the factors that contributed to the effectiveness of the role.However, limited literature was found, either internationally or locally, that explored the personal experiences of CHWs, the challenges of their role, and their needs for ongoing training, professional development, support and supervision.

RESEARCH BRIEF Method
The aim of this study was to explore the role of CSWs in the Aotearoa New Zealand healthcare setting, to focus on gaining a better understanding of the needs for ongoing training, support and professional development.A qualitative, explorative approach was thus selected as being the most appropriate for this study, as it is able to place an emphasis on the meaning of participant experiences, providing insight into the depth of understanding and knowledge required.
This article is based on a research study completed and submitted as part of a portfolio as a requirement for a Masters in Health Science degree at the University of Auckland.Ethical approval for the study was sought from the University of Auckland Human Participants' Ethics Committee, and approval given for the study to proceed.
The study was based in the Auckland central area, recognised as the most ethnically and linguistically diverse city in Aotearoa New Zealand.Participation in the study was restricted to participants employed in a CSW role in a healthcare setting within the region.Participants were selected using a purposive sampling technique with a total of five participants recruited for the study.
The five participants recruited were all employed in a CSW role by healthcare services within the Auckland region, including two District Health Boards, a Primary Health Organisation (PHOs), and a non-governmental organisation (NGO).All five participants (three female and two male) were themselves migrants, coming from areas in the Asia region, including China, India and Hong Kong.
Although, both the Chinese and Indian communities represent the largest Asian communities within Auckland (Walker, 2014), employers were not interviewed for the study, so the recruitment rationale for these workers was not specified.
The qualifications and experience of participants varied, with all of them holding a professional healthcare qualification or having experience in a healthcare or disability setting.The contribution of prior training and/or work experience to the understanding of their current CSW role was acknowledged by all participants.
Data were collected using semi-structured in-depth interviews.The interviews were conducted in English, even though it was acknowledged that, for some participants, English was not their first language.The interviews were digitally recorded and then transcribed.The data were then coded and a thematic analysis using a general inductive approach was adopted to analyse the data.Advice was sought from a Chinese cultural advisor regarding any potential cultural issues that may arise, and care was taken throughout the process to ensure any cultural norms and practices were adhered to.

Findings Describing the role
Although participants were employed in a variety of healthcare settings, several common functions and tasks of the role were identified.The provision of cultural support and cultural guidance was identified as a main component of the role.
The term bridge was used by participants to describe the dual focus of the CSW role, to support patients and families and to provide cultural support and advice to their colleagues and to the greater organisation.One participant, using the bridge metaphor to describe the role, states: "The basic role is about emotional support, cultural support for patients and families, and also we give cultural advice for healthcare staff . . .co-ordination.To build a bridge between patient and the staff" (Participant 4).
Another major theme identified was the personal motivation of the participants and their commitment to their own communities.

QUALITATIVE RESEARCH
This commitment was demonstrated in many ways, including: working additional unpaid hours; the seeking-out of training and development opportunities to increase their skills and knowledge; and their endeavours to build strengths and resources within their communities.An example of this potential for community development was when a participant described noticing that many clients were facing the same issues, and this led to the establishment of a support group for service users.
The relationship between the CSW role and social work emerged throughout the data, with participants recognising the similarity between their work and that of social workers when describing the tasks associated with the role.This included providing support, information, advocacy and also their role in community development as a way to better support patients and their families.
Developing the CSW role to become more like social work was also identified by participants as a way of receiving more recognition for the role and work they do.One participant, using the social work role as an example of the importance of having a clearer role title and description, states: "They do need that role, kind of set up a proper role, a title of the name, and then maybe we can say like social worker, they have their title, and we can have our own title so making clearly what our role is and then people more understand what we need" (Participant 4).

Cultural support
All the participants acknowledged the importance of cultural understanding and demonstrated a strong commitment to the delivery of culturally appropriate healthcare.Being able to offer an understanding of, and insight into, cultural beliefs and behaviours was seen as an important way to improve outcomes for patients, as well as the cultural understanding and knowledge of health professionals.
Participants gave examples of their role providing cultural support in palliative and end-of-life care, where differing cultural values can emerge and have the potential to cause distress.They described liaising with hospital staff to ensure the cultural beliefs of patients and families are recognised and considered in the process, and ensuring that bad news is delivered in a culturally sensitive and appropriate way.Recognising how attention given to addressing these relatively small issues makes the patient feel respected and cared for, enabling the building of rapport and trust which are essential components of a positive, therapeutic relationship between the patient and the healthcare service.
The importance of good communication was identified by participants as an important factor in reducing the risk of misunderstandings, and providing positive and satisfying interactions between patients and health professionals.They described the importance of the connection established through language and how this creates an effective way to establish rapport with clients and families.However, participants were very clear that their role was not that of an interpreter.
When participants described creating their connection with clients, they highlighted the importance of, not only a common cultural background, but also the shared experience of migration.The experience of leaving family, and knowledge of the difficulties and challenges faced by migrants in a new country create a bond based on this shared experience and understanding.While some participants shared in detail their story of migration to Aotearoa New Zealand-the issues and challenges faced when building a life in a new country-others also referred to the huge impact of migration and resettlement.
Supporting the emotional and psychological needs of clients was seen as a key function of the role, by being able to act as a confidante and offer a sympathetic ear for service users.

Discussion
As healthcare providers meet the challenge of delivering healthcare services to increasingly ethnically and linguistically diverse communities, cross-cultural understanding and communication have become increasingly critical features of effective healthcare delivery.While there is an emphasis on delivering equity in healthcare services, the importance of acknowledging and embracing cultural differences needs to be recognised (Henderson & Kendall, 2011).
The value of cultural understanding and support, as well as the impact of the connection that is created with someone who shares the same cultural background, language and experience of migration, is a key factor in the establishment of trust and rapport, the foundation for an effective therapeutic relationship in the healthcare setting.However, a significant challenge for the exploration and understanding of the contribution of the CSW role in the healthcare setting is the lack of clarity around the description and functions of the role.This challenge, identified in the literature, hinders the ability to generate meaningful data about the role and its acceptance within the healthcare setting (Love et al., 1997).
This lack of clarity combined with the current lack of specific training and development opportunities for CSWs here in Aotearoa New Zealand is reflected in the findings from overseas studies.Rosenthal et al.'s (2011) most recent study into CHW training programmes in the USA echoed the results of their previous study in 1998, in finding that the most common training provided was stated as "on the job" (2011, p. 256).

QUALITATIVE RESEARCH
Despite this, participants demonstrated a strong commitment to training and ongoing professional development, and to career advancement in the CSW role.
For CSWs to become accepted and integrated into healthcare delivery, there needs to be an investment by healthcare providers in their training, ongoing professional development and support.CSWs are themselves members of our migrant and refugee communities and, like others, are seeking meaningful employment that offers opportunities for career advancement and appropriate recognition and remuneration.

Study limitations
This small study, limited to the scope available within a research portfolio, offers an insight into the challenges faced by CSWs in healthcare settings within the Auckland area.While the five participants interviewed for the study provide rich data on the lived experience of CSWs, the data cannot be generalised to all CSWs.A future study that includes the perspectives of those who are impacted by the CSW role-including other stakeholders, service users and colleagues of CSWs-would provide a richer and more detailed narrative.

Conclusion
Although only a small study, findings describe a highly motivated workforce, with these CSWs committed to their role as a bridge between ethnic communities and healthcare providers.It highlights the importance of the connection made through a shared cultural background, and reinforces the value of this connection in establishing the rapport and trust essential for an effective interaction between health provider and health service user.Despite the challenges that exist for CSWs, opportunities for the role to be developed and strengthened also exist.The introduction of specific training and mentoring programmes will allow the role to be better understood, more integrated into the healthcare setting, and will allow the valuable contribution made by these workers within the healthcare setting to be appropriately recognised and rewarded.