Doctor–patient communication, by creating good interpersonal relationships, allowing the exchange of information and facilitating treatment-related decisions, is fundamental to optimal medical care.1 Effective communication correlates with improved outcomes, including physiological criteria such as levels of blood pressure and blood sugar.2 Conversely, professional, language and cultural barriers can impede communication.3,4
Few investigators have studied the extent and consequences of miscommunication in Australian Aboriginal healthcare,5 an area in which effective communication is extremely important.6 Previous studies involving interviews with service providers and Aboriginal patients have identified significant concerns about communication.7-9 Some researchers have identified an acceptance, as the norm, of a grossly deficient standard of cross-cultural communication.8 We believe that previous studies, based as they have been on indirect reporting or simulated interactions10 (rather than direct observation and analysis of the interaction itself), probably understate the degree of miscommunication. The communication gap may be so wide, and so ingrained in healthcare, that it is not even perceived by staff.11 Similar misunderstandings in Australian court cases often go unrecognised by the participants.12
In our study of staff–patient interactions in a dialysis unit in Darwin, NT, we attempted to develop a more informed understanding of intercultural communication between Aboriginal patients and non-Aboriginal staff and to devise strategies for improvement.
The participants were patients and staff of a satellite dialysis unit in suburban Darwin. The interactions on which our study is based occurred between March and July 2001. The patients came from the Yolngu language group in north-east Arnhem Land. Five interactions were videotaped, each involving a single patient (although family members were present on two of these occasions). Four interactions involved a single staff member and one involved a doctor and a nurse. The interviews occurred at the dialysis unit and at a remote Aboriginal community several hundred kilometres from Darwin.
We used qualitative research methods to reflect the perspectives of all participants. The research design drew on "grounded theory", which describes the inductive process of identifying analytical categories to describe and explain key issues as they emerge from the data.13 Hypotheses were developed from the ground up, rather than being defined a priori, as is usually done in quantitative research.
Recognising that the effectiveness of communication is inextricably connected with structural issues of poverty, dispossession, marginalisation, low educational achievement and racial discrimination,7 we chose a "participatory action" approach. This is a style of research in which the demarcation between "researcher" and "subject" is blurred, research design is negotiated, and the participants perceive the need to change and are willing to participate actively in the change process.14 The research process is illustrated in Box 1.
Five clinical interactions, identified beforehand in consultation with both patients and staff, were selected. These concerned diagnosis, treatment and chronic disease management. Staff were asked to follow their usual practice regarding the use of interpreters. The interactions included two medical reviews (one with a patient on regular haemodialysis and one with a patient with chronic renal disease close to needing maintenance dialysis), two education sessions (a nurse providing feedback on blood-test results and a consultation between an allied health professional and a new patient), and an interaction between a nurse and a patient during dialysis.
We selected participants using a "maximum variation sampling approach", wherein a small sample is selected to reflect maximum diversity across specified attributes.16 The participants covered as wide a range as possible in terms of age, sex, duration of renal experience (receiving or providing treatment), degree of familiarity with the culture and language of the other group, and experience in cross-cultural communication.
The data from all sources were integrated to explore the extent of miscommunication; the cultural, linguistic and systemic factors influencing communication; the effectiveness of communication strategies being used; and possible strategies for improving communication.
The video descriptions and interview transcripts were entered into QSR NVivo,15 a computer software package that assists in managing qualitative data. Categories used in analysis were derived primarily from the data and through sequential analysis. To strengthen the validity of our analysis, we used "triangulation" (the comparison of results from two or more different methods of data collection) and "respondent validation" (cross-checking interim findings with the participants).17,18
A picture emerged of serious miscommunication, often unrecognised by participants, regarding fundamental issues in diagnosis, treatment and prevention. Although there were many differences of goals and structure observed in the interactions, common themes relating to miscommunication emerged. Factors impeding communication included lack of control by the patient, differing modes of discourse, dominance of the biomedical model, lack of shared knowledge and understanding, cultural and linguistic distance, lack of staff training in inter-cultural communication, and failure to call on trained interpreters (see Box 2 and Box 3).
Western modes of discourse dominated, with Yolngu modes being marginalised or excluded. Question-and-answer routines, central to Western discourse, do not feature commonly in Yolngu discourse, particularly in relation to personal topics. In Yolngu discourse, the question-and-answer approach is complicated by factors such as cultural restrictions on who may ask for, or give, specific information. It is generally considered impolite to directly contradict or to respond negatively, particularly in encounters of unequal power or when the participants lack a close relationship. The patients in our study repeatedly gave responses that they believed the staff wanted to hear, a practice known in linguistics as "gratuitous concurrence".19 Triangulation showed that these responses did not represent the patient's true feelings or experience, but were attempts to give "required" or "correct" responses, as in the following example:
The physician believed that the patient had a clear understanding of the question and was describing the amount of fluid drunk daily. However, it later became clear that the patient responded this way because she knew what was expected. Her understanding of fluid restriction was that she should drink only two cups of "fizzy drink" per day, but that drinking tea or water whenever she felt like it was acceptable. Questions requiring a "yes"/"no" response were particularly susceptible to gratuitous concurrence. A nurse made the following comment:
The discourse in the interactions focused on renal function, renal failure, monitoring of and adherence to dialysis, and dietary and medication regimens. Non-medical aspects were excluded or marginalised. Yolngu priorities, which emerged in subsequent interviews and informal discussions, were social, cultural and economic, relating primarily to (currently) unavoidable relocation to Darwin if patients wished to access necessary treatment. One patient illustrated her problems with living in Darwin:
I told her [the staff member] the truth . . . that I wasn't getting enough [food]. When I get my allowance, they take all the money for accommodation and leave only $30 for food — that's not enough.
Yolngu priorities, which directly affect clinical management, were rarely raised, and, when raised, were either not pursued or were brushed aside. Patients had no explicit opportunities to discuss their own approaches to managing their health. For example, in two interactions, they attempted to talk about Yolngu knowledge and management practices (related to traditional foods), but their contributions were either not understood or not acknowledged.
None of the staff speak an Aboriginal language and none of their Yolngu patients speak English as a first language. Furthermore, none of the staff had received any formal training in inter-cultural communication. Even general cultural awareness training, which is increasingly available to staff, had been utilised to a limited extent and to minimal effect. One physician recalled his only training experience in cultural awareness:
In Alice Springs, I probably had a day's training. It would have been a standard thing, and it was brief, and I have no memory of it.
And yet he found that intercultural communication was
There were organisational barriers to formal training, as a renal nurse related:
For most of the staff, learning occurred "on the job", but this had serious limitations, as a physician reflected:
Until recently, there was no alternative to attempting whatever communication was possible through the assistance of whoever was available. In the absence of professional interpreters, family members had to suffice — a seriously inadequate practice.20 Although an Aboriginal Interpreter Service providing Yolngu language speakers now exists, changes in practice are occurring only slowly. In the interactions observed in our study, the closest any of the staff or patients came to seeking the assistance of a professional interpreter was to call on the assistance of a family member who had some informal interpreting experience.
Our study demonstrates that renal staff and Yolngu patients rarely achieved a shared understanding of key concepts. Consequently, communication was seriously limited and quality of care compromised. There was little indication that either staff or patients had, before or during these encounters, considered the potential for miscommunication. Even if this had occurred, staff had no tools or guidelines for assessing its extent. Our findings suggest that any substantial improvement in communication, and in ensuing health outcomes, requires fundamental change in the delivery of healthcare — in particular, in constructing a shared understanding, from the perspectives of both staff and patients, of physiological processes, renal disease and treatment options.
Previous research has been based on interviews with service providers, and sometimes with Aboriginal patients, about their perception of communication issues. Our study, by contrast, involved direct observation of interactions, and then, with the input of all participants, sequential analysis. We have shown that miscommunication can easily go unrecognised.
While previous studies of communication breakdown have usually focused on the clinical interaction, we looked beyond this. Our findings enabled us to understand both sides and to see the clinical interaction within the social, cultural and political context relevant to the delivery of healthcare to Aboriginal people.
We believe the qualitative research methods we used were appropriate. It could be argued that our findings may not be generalisable to staff–patient communication in the entire renal unit in which the research occurred, nor transferable to other patient-care settings. However, we believe that the methods of triangulation, respondent validation and maximum variation sampling strengthen the validity of our findings.
Videotaping the interactions did not appear to fundamentally alter the communication strategies used by staff. In any case, we would expect any bias, arising through participants' knowledge of being observed, to be towards more effective rather than less effective communication. Our results support similar findings of miscommunication in other Aboriginal health research8,11,21 and in international cross-cultural research.1,3 We believe that our research findings are both credible and relevant to the delivery of healthcare to Aboriginal people, and that similar miscommunication problems are likely to exist in other healthcare settings in which there are people whose first language is not English.
Fundamental change is required to achieve effective communication with Aboriginal patients who have renal disease. We will not be able to deliver optimal care without striking a balance between the staff's medical priorities and the patients' social needs. Some strategies for improving communication are set out in Box 4. Planning and implementing such strategies for the Yolngu will require collaboration between staff, patients and patients' families. We are currently developing such a project. Short of such radical change, attempts to improve communication can meet with only limited success.
Abstract
Objectives: To identify factors limiting the effectiveness of communication between Aboriginal patients with end-stage renal disease and healthcare workers, and to identify strategies for improving communication.
Design: Qualitative study, gathering data through (a) videotaped interactions between patients and staff, and (b) in-depth interviews with all participants, in their first language, about their perceptions of the interaction, their interpretation of the video record and their broader experience with intercultural communication.
Setting: A satellite dialysis unit in suburban Darwin, Northern Territory. The interactions occurred between March and July 2001.
Participants: Aboriginal patients from the Yolngu language group of north-east Arnhem Land and their medical, nursing and allied professional carers.
Main outcome measures: Factors influencing the quality of communication.
Results: A shared understanding of key concepts was rarely achieved. Miscommunication often went unrecognised. Sources of miscommunication included lack of patient control over the language, timing, content and circumstances of interactions; differing modes of discourse; dominance of biomedical knowledge and marginalisation of Yolngu knowledge; absence of opportunities and resources to construct a body of shared understanding; cultural and linguistic distance; lack of staff training in intercultural communication; and lack of involvement of trained interpreters.
Conclusions: Miscommunication is pervasive. Trained interpreters provide only a partial solution. Fundamental change is required for Aboriginal patients to have significant input into the management of their illness. Educational resources are needed to facilitate a shared understanding, not only of renal physiology, disease and treatment, but also of the cultural, social and economic dimensions of the illness experience of Aboriginal people.