, 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.
1: The research process
* Obtaining consent, exit interviews, feedback and in-depth interviews were undertaken with participants in their first language
2: Sample interaction (A)
Setting: The doctor's office in a remote community 500 kilometres from Darwin.
Participants: Mr "A", a 24-year-old man with chronic renal disease who recently had a prolonged admission to Royal Darwin Hospital, during which he required temporary dialysis. He lives with his mother and grandmother, and is fluent in Yolngu languages but not in English. He will need relocation to Darwin within two years for maintenance dialysis.
Dr "B", a 38-year-old male physici