Improving outcomes for hospitalised First Nations peoples through greater cultural safety and better communication: the Communicate Study Partnership study protocol

A multicomponent intervention will be implemented over 4 years. Impact will be evaluated longitudinally using data collected during baseline periods prior to activity implementation and study implementation periods. The baseline period is July 1, 2020, to June 30, 2022 and activity period July 1, 2022, to June 30, 2026, for the purposes of quantitative data (Fig. 2). Additionally, individual before-and-after time frames for qualitative data collection will allow comparison of impacts of sequential training sessions run during 2023–2026.

The impact of the activities will be assessed using time-series analysis of quantitative outcomes and qualitative measures of patient-provider interactions and experience (Table 1 and details below). A continuous quality improvement (CQI) approach [19, 20] will ensure data are used pro-actively, through participatory methods that engage and motivate relevant front-line and executive staff from health and interpreter services. Outcome measures include cultural safety, as experienced by First Nations peoples treated at participating hospitals, and proportion of admitted First Nations patients who self-discharge (Table 3).

Overarching program evaluation will use the RE-AIM model (Reach, Effectiveness, Adoption, Implementation, Maintenance — Table 4) [22]. 

Regarding terminology, we use ‘First Nations’ which recognises the diversity of nations who hold unceded sovereignty over Australia. We use ‘Aboriginal’ as required per organisational naming conventions. We use the term ‘White’ for nonindigenous persons in keeping with definitions of White as a social category of people who, in societies with European-origin dominant cultures such as Australia, knowingly or unknowingly participate in a racialized society that positions them as superior [23, 24].

Participating sites are hospitals in the ‘Top End’, NT, Australia: Royal Darwin Hospital (RDH), Katherine Hospital (KH), and Gove District Hospital (GDH). We use participatory action research (PAR) in which stakeholders, participants and researchers collaborate to develop and enact real-world solutions to complex problems within Top End hospitals [25]. PAR projects value the experiential knowledge of marginalised peoples; the model is increasingly used in health research with First Nations communities [26]. Communicate Study implementers report regularly to the Aboriginal Health Committee of the NT Government Department of Health, and the committees which guide the implementation of the Australian National Safety and Quality Health Service (NSQHS) Standards (‘partnering with consumers’, standard 2) and ‘communicating for safety’, standard 6).

Decolonising philosophies informing project design include cultural safety [27, 28], critical race theory [29] and Freirean pedagogy [13]. Cultural safety is the provision of an environment and practices that are safe for peoples of all ethnicities. It is akin to antiracism, ‘about the analysis of power and not the customs and habits of anybody’ [27]. Cultural safety in healthcare is the responsibility of healthcare providers and institutions to learn and change, and the extent to which cultural safety is achieved is determined by patients. These philosophies are linked by the following: (1) a critical focus on colonisers, (2) foregrounding race and racism, (3) a commitment to social justice and participatory approaches, (4) the assertion that dialogue between seemingly disparate groups is paramount to creating societal change and (5) the understanding that individuals who develop critical consciousness are capable of identifying power dynamics and creating a more equitable society [13, 27, 29]. These philosophies are applicable to our research in healthcare because they focus on redressing the power imbalance between healthcare providers (in positions of power) and patients (whose status as patient compounds existing disempowerment and marginalisation), by encouraging development of new perspectives through dialogue (direct or indirect by way of podcasts or other forms of storytelling). A key concept is to share ‘counterstories’ (described in critical race theory as a strategy to dismantle racist thinking [30]) from First Nations peoples to challenge negative stereotypes. By engaging with counterstories, healthcare providers can reflect on the pervasive impacts of colonisation as the fundamental cause of ill health [31]. The interventions designed for healthcare providers (‘Ask the Specialist Plus’ training and the cultural safety champions group) encourage staff to question and reflect on medical culture, Whiteness, racism and colonisation [32].

The Freirean concept of ‘problem-posing education’ [13] has inspired our training interventions. Problem-posing education encourages learners to identify problems they face, in response to which teachers create relevant curricula to help solve those problems. It has been hypothesised that this approach can challenge the dominant paradigm by encouraging students to critically reflect rather than being deposited with information that reinforces the status quo [33]. This model was used to develop the Ask the Specialist podcast and the health education for hospital-based interpreters.

Implementation theories, models and frameworks are summarised in Table 2. The ‘COM-B’ system (capability, opportunity, motivation) informs study activities, recognising these attributes are central to achieving behaviour change [34]. The Communicate Study activities have accordingly been devised to address capability, opportunity and motivation under the headings of supply, demand, efficiency and effectiveness. The ‘supply–demand’ cycle borrowed from the manufacturing sector serves as a relevant determinant framework of interpreter uptake [35]. Supply of Aboriginal interpreters requires recruitment of bilingual experts into employment as interpreters (opportunity), training, certification and mentoring (capability) and provision of rewarding career pathways (motivation). Demand is generated through more culturally safe health systems where cultural safety is prioritised and the benefits are visible and rewarded (motivation) and through better knowledge among healthcare providers that their clients speak diverse languages, about the names of those languages, and about how to access interpreters (capability and opportunity). Efficiency is achieved through simplified booking processes (capability); visibility of interpreters in areas of need such as wards, emergency, outpatient clinics and availability of enough interpreters across diverse Aboriginal languages (opportunity); and continuous quality improvement data feedback to motivate greater interpreter uptake (motivation). Effectiveness is achieved when healthcare providers are competent and trained in working with interpreters (capability), have time and space available for appropriate communication (opportunity), when healthcare providers and patients both see positive outcomes from interpreter use and when senior clinicians and executive leaders prioritise and value interpreter engagement (motivation).

A participatory approach will be used as noted, incorporating CQI that builds comprehensively on the plan-do-study-act cycle [36]. CQI will be achieved through quarterly meetings of key health service providers (clinical champions, working group members, heads of departments), investigators and project team members, to motivate practice change. Infographics and plots will be prepared by the project team to present quarterly data broken down by hospital and ward. This will include ‘cascades of care’ plots showing numbers of inpatients in relation to Aboriginal languages, interpreter bookings and booking completions. Length of stay, proportion of discharges ending in self-discharge, 30-day readmissions and key themes and quotations from qualitative data will also be shared in CQI sessions. A summary will be included in the quarterly study newsletter. These meetings will provide opportunities to identify and troubleshoot barriers and implement sustainable improvements through the partnership model with the relevant service providers.

Activities are summarised in the Template for Intervention Description and Replication (TIDieR) checklist [18] (Supplementary Table) and described here in relation to each aim (Table 1).

Aim 1 is to transform the culture of healthcare systems and to achieve excellence in providing care for First Nations peoples. This will be addressed through provision of cultural safety training and creating a community of practice of culturally safe clinicians.

‘Ask the Specialist Plus’ is a structured programme developed by the Communicate Study team to promote antiracism within NT hospitals. It is an 8-week programme based on the ‘Ask the Specialist’ podcast [37]. The ‘Plus’ refers to added activities to support critical reflection on the contents of the podcast. Participants listen to a podcast episode (< 18 min) and then attend a 1-h small-group facilitated discussion with a topic focus (Table 5) during the team’s usual weekly teaching slot. Group size is preferably less than 25 to encourage participation and sharing of ideas in a safe, supportive environment. Facilitators can use materials and slides prepared by V. K. and S. Y. M. as a prompt for discussion points. Embedding ‘Ask the Specialist Plus’ in allocated in-service and clinical teaching times ensures that cultural safety training is valued as much as other clinical skills, and momentum can be amplified as the whole team (students through to directors and multidisciplinary healthcare providers) are all upskilled together, to put learning directly into practice on the wards. This programme was piloted in 2021 in Royal Darwin Hospital’s Department of Women and Children’s Health, and endocrinology departments, demonstrating feasibility and acceptability. Preliminary findings from feedback surveys indicated high satisfaction and a request for more such training (unpublished).

The staff who attend the training will also receive a printed and laminated cultural safety communication checklist (8 cm by 8 cm square) to be attached to staff identification lanyards (Fig. 3). The checklist was inspired by work undertaken with clinicians in New South Wales, Australia [38], who identified the need to have a self-assessment checklist to guide their practice with First Nations families. We adapted the checklist for use in Top End hospitals, in consultation with the developers, and it was endorsed for piloting by the NT Aboriginal Health Committee.

In addition to ‘Ask the Specialist Plus’, a community of practice of culturally safe clinicians we refer to as champions of cultural safety will be supported by a chat platform and seminars provided by invited experts, detailed below.