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.
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.
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