Improving Clinician‐Patient Communication in Aboriginal Health Care: Barriers and Enablers to Implementing Culturally Informed Communication Training (Clinical Yarning)

Ivan Lin, Deborah G Balmer, Charmaine Green Smith, Di Franklin, Kelsie Crowe, Peter O'Sullivan, Jonathan Bullen, Dawn Bessarab

Abstract

ABSTRACTObjectiveThis study examines barriers and enablers to implementing Clinical Yarning into health care from the perspective of health care staff.SettingThe Midwest Region (> 60,000 km2), Western Australia (WA).DesignSemi‐structured interviews with health care practitioners across four regional, rural and remote centers. Interview schedule was drawn from the Theoretical Domains Framework (TDF). Interviews were transcribed verbatim and analysed using inductive and framework analysis, informed by the TDF and Mechanisms of Action.ResultsInterviews with 53 health care practitioners (17% Aboriginal, 83% non‐Aboriginal) ranged from 14 to 60 min in length. Barriers and enablers coalesced around three main themes: knowledge/perceptions of Clinical Yarning, training practices in general and Clinical Yarning specifically, and environmental conditions including general cultural safety and executive support. The barriers and enablers found in each of the domains lead to implementation strategies which use program champions and executive support, build on the positivity towards Clinical Yarning, pay attention to training delivery modes like including local cultural experts where able and acknowledge the larger cultural safety/security barriers within the health service. The barriers presented by workforce challenges are important key variables in any success of the Clinical Yarning intervention.ConclusionThe documented enablers and barriers to implementing Clinical Yarning in the Midwest when viewed through a TDF/MoA framework provide a way to create a systematic implementation strategy to address the identified barriers and enablers. The findings have implications for other health services wishing to implement Clinical Yarning as well as culturally secure health care more broadly.
Key PointsWhat is already known on this topic
Implementing a skills‐based communication training into mainstream healthcare that acknowledges the specific cultural needs of Indigenous Australians is challenging.Many of those barriers and enablers have been generally documented in the literature and others may be unique to the implementation context and training focus.
What this study adds
Clinical Yarning implementation was influenced by three key factors: staff knowledge and perceptions of Clinical Yarning, training approaches—generally and Clinical Yarning specifically and organizational/environmental conditions.The use of a Theoretical Domains Framework/Mechanisms of Action approach identified practical strategies to address barriers and strengthen enablers.This study may provide a template for others to use the same framework to plan and execute an implementation project for communication training.

Background

Effective communication between patients and health care practitioners (HCPs) is the foundation for safe, high quality health care that is valued by patients [, , ]. Improving health care communication is a priority consistently reported by Aboriginal and Torres Strait Islander people (henceforth respectfully referred to as Aboriginal reflecting the Western Australian location of the study) across diverse health settings and health conditions including cancer services [] chronic diseases [], pain [] and emergency care []. For many Aboriginal patients, ineffective communication with HCPs results in patients not being appropriately informed about their health condition(s), unmotivated to engage in care, mistrusting of health services and disengaged from care [, , ]. Effective communication, alongside a well‐resourced Indigenous health workforce, trusting relationships [] and supportive health care systems that value Indigenous peoples' cultural knowledge, beliefs and values, is critical to culturally safe health care []. Improving clinical communication in Aboriginal health care is therefore an important priority.

Clinical Yarning is a framework that has been developed as a patient‐centred communication approach in Aboriginal health care []. Clinical Yarning (CY) was adapted from the seminal work of Bessarab and Ng'andu in research yarning []. Clinical Yarning re‐frames clinical communication as a social, diagnostic and management yarn, mirroring the reciprocal, two‐way, conversational informal communication approach used by Aboriginal people when yarning []. Further details of CY and its background are explored fully in earlier work []; however, in summary, the CY program focuses on equipping health care providers with practical communication skills to enhance their clinical practice. CY preferences patient connectedness and building trust. Training to support HCPs in a CY approach is offered through in‐person workshops in small group settings with or without online CY eLearning modules. Previous studies evaluating clinicians' perspectives reported strong support for CY and increased clinician self‐reported knowledge, confidence and skills communicating with Aboriginal patients [, ].

The Midwest region of WA covers an area of 605 000 km2 with a population of over 54 500 people. The region is a quarter of WA's land mass, with most of the population resident in one larger regional city. The Midwest area in the study is the land of the Yamatji peoples; Wajarri is the predominant language. Health services in the region include regional, district and small hospitals, health centres and remote area clinics []. Approximately 10% of the population in the Midwest Region are Aboriginal and/or Torres Strait Islander []. Improving the health of Aboriginal people is a priority for the local health service [, ].

The paper reports on the first phase of a project to implement CY in the Midwest region, Western Australia (WA). The study takes a systematic implementation science approach to explore barriers and enablers to CY. This information was used to plan an implementation strategy and we anticipate findings from that will be useful to other health services interested in implementing CY or other programmes to improve communication or cultural safety.

Method

The overall CY project is a four‐phased implementation [] study (see Figure ). This paper reports on one aspect of the first phase, a qualitative investigation of the barriers and enablers to implementing CY across the Midwest region [see [] for details] using semi‐structured interviews with health care staff, either individually or as part of a small group.

Health staff from across the government health service in the Midwest were recruited using purposive sampling []. Initially, an organizational map was developed in order to reflect different regions, areas within the health care service and professional groups. Participants were sought from nursing, medical, allied health, Aboriginal Liaison Officers and managerial areas with the invitation, participant information sheets and consent sent via email. Some participants were also followed up by phone. Signed participant consents were returned prior to interviews or consented at the interviews. A focus was also made to include, where possible, self‐identifying Aboriginal staff working in any of these areas within the Midwest. The aim was also to recruit from across six sites within the Midwest area (classified using the Australian Government's Modified Monash Model (MMM) 2023 []) and to get a broad range of views from as broad a range of staff as possible, with stratification used to ensure differing levels of seniority and professional group inclusion.

Ethics approvals for this study were gained from WA Health Central Human Research Ethics Committee (#RGS5764), the WA Aboriginal Health Ethics Committee (#1217) and the University of Western Australia Ethics Committee (#ET000489). The research is funded by a grant from the Future Health Research and Innovation Fund, Implementation Science Fellowship (ISF2021), Department of Health, Western Australia and was a collaboration with the Western Australian Country Health Service (WACHS).

Research Team and Cultural Governance

A central principle of this work was the ‘built‐in’ processes to the way research was conducted to ensure the cultural rights, values and expectations were upheld and promoted []. The project team included Aboriginal researchers (CGS, DB, JB, TP, KMC) as well as other researchers with a range of experience in Aboriginal health research (senior to developing) (IL, PO, DGB, DF, KC). Team members directly involved in field work (TP, IL, DGB, KC: 2 male, 2 female) brought expertise and experience in implementation science, qualitative research and interviewing, physiotherapy, education/teaching, health literacy and Aboriginal cultural knowledge. Two advisory groups were integral to guiding the work throughout: an Aboriginal Community Advisory Group (CAG) consisting of six Aboriginal community members and a Stakeholder Advisory Group consisting of health service and academic partners which included Aboriginal members. The local Aboriginal community‐controlled health service offered strong support for the project including a staff member on the Stakeholder Advisory Group.

Data Collection and Analysis

Initial intentional contact to build an organizational schemata took place with many of these initial contacts known to the lead investigator owing to years of residence in the study area. Recruitment therefore of participants and associated logistics was done by DGB, a relative newcomer to the district with few prior connections. An interview schedule (Data ) was developed collaboratively, using the 14 domains in the Theoretical Domains Framework (TDF) to structure the exploration into barriers and enablers from clinician and health staff perspectives [, ]. The TDF is a synthesis of 33 theories of behaviour and behaviour change, used for examining implementation of new practices in healthcare []. The TDF enables a comprehensive way to explore the determinants of clinician behaviour and provides a theoretical lens through which to understand health care practices, develop implementation approaches, evaluate change and replicate elsewhere (See Table for domains).

Inclusion criteria for participant interviews were (a) employee of the government health service, (b) over the age of 18, (c) from a range of health professionals in the region, reflected in the organizational map developed initially, and a role either patient‐facing or in health service management. Participants were excluded if they did not meet these criteria. Interviews were conducted in participants' workplaces, either in person or virtually. Participants were interviewed individually or alongside and with colleagues, reflecting internal working relationships. Field notes were kept after some interviews to both record events and detail researcher reflexivity. The research consent form gave participants the option to review their own transcript, which no one accepted. The interview schedule was reviewed together with the research team prior to research commencing. Often there were two researchers at the interviews, which was part of capacity building as well as supporting consistent interpretation across the group. Researcher reflection and de‐briefing sessions were held throughout the data collection phase to reflect on the interviews and to support consistency of interview practice. The interview schedule itself (Data ) was not adjusted during the data collection, but adjustments were made to interview technique, for example, pausing or using the prompts better for more specific responses. Interviews continued until both our purposive sample aims were reached and further data collection was yielding few additional insights.

Data analysis began concurrently with interviews, allowing the back and forth movement between the existing data and reflection on ways to improve on data quality as collection progressed []. No repeat interviews were conducted. Participants had the option of agreeing to receive a summary of the study. Interviews were audio recorded and transcribed using a paid transcription software [] followed by detailed checking and revision by the researchers, before being de‐identified.

Our objective was to identify barriers and enablers to implementing CY and link these to their underlying behavioural determinants, to be used later to identify suitable implementation interventions or ‘behaviour change techniques’. Analysis started initially with inductive methods where transcripts of interviews were examined for potential dominant coding categories prior to applying the pre‐defined framework used in the deductive methods. Deductive methods [] were applied using the Theoretical Domains Framework [] and 12 additional theoretical constructs identified that influence behaviour [] giving, in total, 26 Mechanisms of Action (MoA), for example, values, general attitudes/beliefs. MoAs are defined as the actions or processes an implementation strategy takes to achieve the desired outcomes []. Transcripts were mapped on to these to explore the behaviours which may be barriers or enablers to implementing Clinical Yarning. Initially three interviews were selected as coding moderation samples [, ] and coded separately by researchers with interpretations discussed and coding agreed on where there was variation. Researchers thus became thoroughly familiar with the data set, having collected the data, checked transcription and noted observations throughout this process. Emergent codes were discussed amongst several members of the research team as a way to deepen investigation of the data. Headline data categories were discussed with the Community Advisory Group and stakeholders to elicit responses and feedback. Frequent review continued to resolve uncertainties in the coding against the MoAs and arrive at MoA informed themes (Tables , , ).

Results

Semi‐structured interviews took place between August 2023 and February 2024. Fifty‐three people were interviewed in 34 interviews. Eight interviews were participant groups with sizes ranging from 2 to 8 people. Two participants were invited to participate but failed to respond or refused. The total audio‐recorded interview data was 16 h and 35 min with interviews/sessions ranging from 14 to 60 min (average length 29 min). Audio‐recorded individual and group interviews were analysed together as one data set and not distinguished according to group size. Interviews ranged across the intended multiple professional groups, including nursing, allied health, medical, Aboriginal liaison officers, healthcare assistants, health management/administrators from across and representing the 6 regions of the project (Table ).

The six geographical areas were represented with two of the more remote areas represented by staff whose areas of responsibility covered these areas. There were 9 participants who self‐identified as Aboriginal. Ethnicity data was not formally collected. The number of participants in the study was dictated by both the project timing deadline and adequate participant coverage across the region and specialties.

The barriers and enablers for the implementation of CY coalesced around three main themes: knowledge/perceptions of Clinical Yarning, training practices in general and CY specifically, environmental conditions including general cultural safety and executive support.

Knowledge/Perception of CY

Generally, there was a neutral to positive response towards the proposed CY training regardless of the specialty area. However, knowledge of the content of CY was limited or vague (Table , subtheme a). Any prior knowledge generally came from clinical staff who were in more senior roles and who had worked for longer periods of time in the region. When participants did not have any background knowledge of Clinical Yarning, many associated it with engagement with Aboriginal patients as well as cultural awareness more generally. This need for cultural awareness was seen as especially important in remote/rural areas where fly‐in‐fly‐out or agency staffing was commonplace and knowledge of the local cultural context was absent (subtheme c). Some nurses saw CY as having to learn a rigid script and ‘just another training program’, while maintaining that working effectively with Aboriginal patients was best learnt on the job through experience (subtheme d).

For one participant, however, CY training was seen as an opportunity to learn their own culture, having grown up and lived away from culture (subtheme e).

Training & CY

Participants' views varied on what the enablers and barriers to implementing CY training for health staff might be. There was a clear preference for face‐to‐face training, as opposed to on‐line training (Table , subtheme a). Face‐to‐face delivery of CY also meant local, trusted Aboriginal cultural expertise could be included. This was seen as critically important, especially by those in more senior roles (Table , subtheme b) and reflected knowledge of the distinctiveness of different Aboriginal cultural groups in different regions, as well as an enthusiasm for more connection to local Aboriginal knowledge holders. There was however an acknowledgement that on‐line learning options allow flexibility and ease of access (subtheme a). In addition, the possibility of gaining educational credit points (e.g., continuous professional development—CPD) from professional registration bodies was mooted as a potential enabler (e.g., medical specialties/nursing/allied health professional bodies).

A significant barrier to training was workforce shortages, staff turnover and, as a result, the high number of agency nursing staff (staff employed on short term contracts through an external workforce agency) in the region, especially in remote sites (subtheme c). Ideally, agency staff should arrive at the location already prepared, including cultural training. However, the need for better trained agency staff, more attuned to the cultural needs of Aboriginal patients, was highlighted especially by senior nurse participants.

Funding arrangements, however, placed the responsibility of training agency staff with the contracting agency, for which the public health system pays a premium. There was a divide between employee types (permanent versus agency) and what training was mandatory for government employees, coupled with the problem of high staff turnover.

Some participants felt the lack of sophistication for provision of cultural security and was a ‘one size fits all which is statewide’ (S036), especially as it relates to cultural training provision.

Another barrier to implementing CY was limited time for training, especially where participation in face‐to‐face training requires staffing backfill and thus adds additional cost. Because of staff turnover, a train‐the‐trainer approach to the training was not seen as viable, with some citing previous cases where it had failed because of that (subtheme d). However, the notion of a ‘champion’ arose as an enabler for CY—champions already employed within the health service with strong support and commitment to seeing CY implemented (subtheme e).

Participants expressed mixed views on whether mandating (i.e., compulsory) CY training would assist implementation (subtheme f). Overall, most participants supported not mandating CY training because there was a large amount of existing mandatory training which exceeded the allocated time available to complete. Wanting to do the training rather than ‘having to do the training’ was viewed as more attractive by most of the respondents, but not all. One Aboriginal participant felt that making the face‐to‐face training mandatory may provoke a backlash from any colleagues with underlying negative attitudes towards a training specifically aimed at communication with Aboriginal patients. However, for staff who were new and/or working in areas of health care with a high number of Aboriginal patients, some saw CY as essential and thus should be mandatory.

Cultural Safety/Security

A significant and unexpected barrier, especially for remote populations, was seeing support for Aboriginal cultural security not embedded systematically into the health care service (Table , subtheme a). Others saw a lack of an overall system for cultural safety as the legacy of health services that were established to serve exclusively the needs of the dominant cultural group. Some anticipated institutional barriers for CY because of the prejudicial views of individual staff members. Though CY training addresses one aspect of culturally safe care, it is the system as a whole which was seen as requiring attention (subtheme a).

The lack of systematic backing for the cultural support (Aboriginal Liaison Officer—ALO) role, both in scope and training was noted by some. Institutional cultural insensitivity was also seen to relate to historical trauma and mistrust (subtheme b) and where improving Aboriginal health was not viewed as a priority, as evidenced by some witnessing the on‐going delays in a long‐planned new health care facility servicing an area with a high Aboriginal population. The expectation that ALOs would take on the cultural trainer role in the CY implementation seemed unrealistic given the work load, expectations, limited number of ALO staff and large variations in employment and training histories. In addition, some participants questioned whether the health service sufficiently supported ALO roles within the organization to work most effectively.

Conversations about CY evoked broader reflection on engaging with Aboriginal patients in clinical practice more generally. The importance of working with Aboriginal staff who worked in health care was highlighted by some. Alternatively, a few health professionals did not see a patient's Aboriginality status as something requiring a specific approach in their clinical practice, rather it was to be guided by the clinical condition being presented (subtheme c). Some participants reported negative views on prior cultural training experiences which did not include a practical component (Table Subtheme e).

The role of the ALOs arose repeatedly in the discussion around cultural awareness, cultural support and especially in relation to being involved in training and supporting Clinical Yarning. One participant expressed the desire to work together with ALOs while providing patient care in order to learn. However, that was countered by others cautioning against further burdening an already over‐stretched workforce (subtheme d). While discussing the role ALOs could have in Clinical Yarning, another observer highlighted the large variation in training that ALOs receive.

These various insights into ALO role and function in the clinical space are both a barrier and an enabler. The expectation that ALOs would take on the cultural trainer role in the CY implementation seemed unrealistic given the workload, expectations, limited number of ALO staff and large variations in employment and training histories (subtheme d). In addition, some participants questioned whether the health service sufficiently supported ALO roles within the organization to work most effectively (Subtheme a).

Discussion

In our study we utilized the TDF to guide interviews with staff and to map emergent themes against domains of the TDF/MoA during analysis (Table ). Enablers were identified and incorporated into Clinical Yarning training, including involving local Aboriginal cultural leaders in program delivery, offering face to face training (as opposed to online), linking training to CPD/CME points, not mandating training and utilizing an existing learning management system to arrange training workshops. Most of these enablers were within a ‘motivation’ behavioural domain []. Partnering with local cultural knowledge‐holders has been recommended to improve cultural safety and Aboriginal health care communication [, ]. Other enablers included a positive attitude towards Clinical Yarning, overall support from health service executives and identifying some staff as clinical champions of the program (general attitude/beliefs, social influence and motivation domains).

Several important barriers were identified within an environmental context and resources domain that were beyond the scope of our project. These included workforce challenges with staff shortages and high turnover, especially in remote areas, and limited time that can be allocated to training due to workforce demands, especially for nursing staff. A high number of agency nursing staff, especially in remote areas, was another barrier as, given the short‐term nature of their work and the extra costs to the health service, agency staff are not supported to undertake training. These findings reflect well established challenges in Australian remote and rural health care [] and are an additional challenge when aiming to implement new health care approaches in this context.

Other significant barriers within the domain of environmental context and resources and general attitudes/beliefs were related to cultural safety more broadly. This included an insufficient number of Aboriginal staff, limited integration of ALOs within the health system, a lack of system to support culturally safe care more broadly and perceived racism within the health service. Clinical Yarning/communication can build culturally safe care, alongside a well‐resourced Indigenous health workforce, trusting relationships, and supportive health systems that include physically welcoming spaces that address racism []. In our project we are targeting communication through Clinical Yarning; however, we do not know if a communication‐focused project, without attention to other elements is sufficient to result in health care change given that these factors are interlinked as part of cultural safety. Nor is it clear whether by addressing communication, there is the potential to influence other aspects of cultural safety.

By identifying barriers and enablers and their associated behavioural domains, we can develop suitable interventions based on evidence‐supported behaviour change techniques to implement in the next project stage []. For example, some participants expressed previous negative experiences of cultural training and were unconvinced Clinical Yarning would be different, thus potentially impacting on the uptake of Clinical Yarning training. This barrier was aligned to the behavioural domain of general attitudes/beliefs. One evidence‐supported behaviour change technique to address general attitudes/beliefs is to present alternative information from a credible source []. Therefore, our strategy will be to develop a communication strategy with senior staff (credible source) [] that reinforces a positive attitude towards Clinical Yarning, distinguishes it from cultural training, reinforces the goal of the project and describes the positive outcomes from previous research findings. By mapping barriers and enablers to behavioural domains and then behaviour change techniques, we can develop a systematic implementation plan that we will re‐visit during the evaluation phase to determine what, why and how interventions did or did not work. Theory‐informed approaches such as this are needed in cultural interventions so as to increase understanding of what works when and to maximize change [].

Several implementation strategies have been previously reported in Aboriginal health care clinical communication research. These include strategies to increase utilization of Aboriginal interpreter services in Australian Northern Territory hospitals [, ], and intercultural exchange and co‐creation of educational process and resources between Yolnu (First Nations Australians from North‐East Arnhem Land) and non‐Indigenous staff from education, health or community services []. One intervention, a multifaceted approach to enhance communication in three Northern Territory hospitals was underpinned by one implementation theory, the COM‐B [] to ensure interventions broadly addressed each area of the model (i.e., capability, opportunity and motivation) although interventions were not tailored in response to data collected in the project []. Clinical Yarning contrasts to previous work because it adopts a behavioural‐skills approach which explicitly aims to change clinician communication practices []. Evidence suggests that Clinical Yarning is highly valued by clinicians [, ] and results in more effective communication practices []. Ultimately, further implementation‐oriented research to improve Aboriginal health care communication is needed in order to understand what interventions are effective, in what context, so these can be applied successfully elsewhere. Further research is also needed on Aboriginal patient experiences of Clinical Yarning.

This study identified a range of barriers and enablers to implement Clinical Yarning within a regional Western Australian health service. Effective communication is a foundation to culturally safe/secure health care [] and a priority in Australian health care []. Although there has been extensive documentation of communication issues in Aboriginal health care, most studies to date have either described these issues [, ] or proposed frameworks/models to improve communication []. Fewer studies have implemented strategies to enhance communication, with fewer still taking a theory‐informed approach [] to this issue. This study applied a theory‐based approach to investigate barriers and enablers to implementing Clinical Yarning which will be used to develop implementation interventions/strategies. Findings are relevant to health services and researchers wishing to enhance clinical communication and cultural safety, and we hope to advance efforts to improve Aboriginal health care clinical communication more broadly.

Limitations & Strengths

The strengths of this study are the diverse perspectives each member of our team contributes as community members, Aboriginal and other researchers, clinicians and health managers to this topic and our systematic approach to advance an important and under‐researched area. There is a broad cross section of health care staff, from different professional groups and geographic sites who participated. A potential limitation is that some rural/remote sites may have unique place‐based opportunities and challenges that may not have been identified. Another potential limitation is the predominance of females in the sample group, and whether findings would have been different if the male/female participant numbers were more balanced. Likewise, there is also an over‐representation of the nursing profession; however, the spread of positions and responsibilities across the organization reflects a predominance of females in those roles making recruitment of male participants not possible. There is also potential for bias (relational, response‐shaping) as the research was conducted in small communities, where researchers are often embedded in that community and thus known to participants. Separate reporting of Aboriginal perspectives was not appropriate because of the small sample and potential identification risks. Further, the application of the TDF/MoA in Aboriginal health research is relatively new. In time, implementation theoretical frameworks that integrate Indigenous approaches with Western implementation theories may be more suitable in Aboriginal health services research.

Conclusion

Taking a systemic theory‐informed approach, we identified important enablers and barriers to implementing Clinical Yarning across a Western Australian regional health service. Identified enablers, including involving local cultural experts, supporting program champions and building on positive regard for the topic and barriers such as prior negative experiences of cultural training, will be used to plan what, how and when to deliver evidence‐informed interventions. A number of environmental/contextual barriers were identified, including a lack of overall cultural safety within the health service and workforce challenges that are beyond the immediate scope of the project and could potentially impact on the success of the interventions. The findings and theoretical approach taken are relevant to health services wishing to improve clinical communication (and cultural safety) and to deepen understanding of how to make change in these areas.

Ethics Statement

Ethics approvals for this study were gained from Western Australia Health Central Human Research Ethics Committee (#RGS5764), Western Australian Aboriginal Health Ethics Committee (#1217) and the University of Western Australia Human Ethics Office (#2023/ET000489).

Lin I., Balmer D. G., Smith C. G., et al., “Improving Clinician‐Patient Communication in Aboriginal Health Care: Barriers and Enablers to Implementing Culturally Informed Communication Training (Clinical Yarning),” Australian Journal of Rural Health
34, no. 5 (2026): e70236, 10.1111/ajr.70236.