re 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, 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 triangu