nt-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 five interactions were video