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.
Extensive prerequisite knowledge is essential for making sense of information about the management of end-stage renal disease. A shared understanding of kidney and heart function, and of the nature of the circulatory system (including, for example, the components and function of blood), is necessary for meaningful discussion about medication, fluid restriction and dialysis. As shared understanding of many of these concepts does not exist, effective communication is seldom achieved.
The vast cultural and linguistic distance between staff and patients in these interactions impeded communication. Staff use of culturally specific terminology was one difficulty. For instance, quantification was a constant problem. Key biomedical issues were expressed quantitatively, including percentage of renal function, number of drinks consumed, amount and frequency of medications, length of visits home, length of time without dialysis, high and low blood pressure, and blood test results. But litres, kilograms, hours, dates and percentages have little, if any, meaning for most Yolngu, while Yolngu ways of expressing quantity and spatial and temporal concepts were completely unknown to staff.
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
. . . an incredibly difficult aspect of working there. I knew that there was next to no communication between me and the patients, which had an obvious impact on what happened.
There were organisational barriers to formal training, as a renal nurse related:
I haven't done a cross-cultural course at all. When I first came up [to Darwin], it wasn't compulsory and I've tried to get in several times over the years and it was either booked out or Renal couldn't relieve me because they didn't have enough staff at the time.
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