Yarning about pain: evaluating communication training for health professionals at persistent pain services in Queensland, Australia

doi:10.21203/rs.3.rs-1740247/v1

Background: Providing cultural education to health professionals is essential in improving the quality of care and the outcomes for Aboriginal and Torres Strait Islander patients. This study reports the evaluation of a novel training workshop used as an intervention to improve communication with Aboriginal and Torres Strait Islander patients at persistent pain services.

Methods: In this single-arm intervention study, health professionals undertook a one-day workshop, which included cultural capability and communication skills training based on a clinical yarning framework. The workshop was delivered across three adult persistent pain clinics in Queensland. At the end of the training, participants completed a retrospective pre/post evaluation questionnaire (5 points Likert scale, 1=very low to 5=very high), to rate their perceived importance of communication training, their knowledge, ability, and confidence to communicate effectively. Participants also rated their satisfaction with the training and suggested improvements for future interventions.

Results: Fifty-seven health professionals were trained (N= 57/111; 51% participation rate), 51 completed an evaluation questionnaire (n=51/57; 90% response rate). Significant improvements in the perceived importance of communication training, knowledge, ability and confidence to effectively communicate with Aboriginal and Torres Strait Islander patients were identified (p<0.001). The greatest increase was in the perceived confidence pre-training mean of 2.96 (SE=0.11) to the post-training mean of 4.02 (SE=0.09).

Conclusion: This patient-centred communication training, delivered through a novel model that combines cultural capability and the clinical yarning framework applied to the pain management setting, was highly acceptable and significantly improved participants’ perceived competence. This method is transferrable to other health system sectors seeking to train their clinical workforce with culturally sensitive communication skills.

training

communication

Aboriginal

Torres Strait Islander

pain

health professionals

The ability to communicate effectively with patients, their families, and other health professionals is an essential competency for clinical practice.¹ Ineffective communication between health professionals and Aboriginal and Torres Strait Islander people living with chronic diseases and other health conditions is a significant barrier to optimal care.^2–5

Communication during a clinical consultation requires both a cognitive understanding of the content to be addressed and process skills to explain the required information. Consequently, the ability to integrate these two domains is critical. Interventions aiming to improve clinical communication skills must consider these domains and how these apply to diverse clinical scenarios.⁶

Pain is one of the most common reasons patients seek healthcare.^7–9 Pain is a significant public health problem, as one in five Australians aged 45 and over are living with persistent pain that causes suffering, reduced quality of life, and disability.¹⁰ Pain is a complex experience, involving physical, psychological, and social distress with characteristics that are particularly challenging to describe.^{11, 12} As pain is a subjective experience, and the expression of pain can be framed by culture¹³ successful pain management depends upon effective communication for clinicians to understand the multidimensional patient experience.¹⁴ If communication between health professionals and patients is ineffective, uncertainty, doubt, and mutual mistrust can occur, negatively affecting the quality of care received.¹⁵

Communication has been identified as the most significant barrier for Aboriginal people when they seek to manage their musculoskeletal pain.¹⁶ Findings from a recent review¹³ demonstrated that in pain management, Aboriginal and Torres Strait Islander patients may hold beliefs about the underlying cause of pain which can differ from health professionals. For example, a patient may decide not to share the origins of their pain because they attribute their pain to a consequence of breaking traditional laws and protocols. Aboriginal and Torres Strait Islander patients were also found to be reluctant to report their pain when they perceived they were not listened to or were not respected.^{13, 17} Further, given the limited knowledge of health professionals about cultural safety and how they apply this concept during pain assessment within an intercultural context, has the potential to negatively impact pain management and aggravate the suffering among Aboriginal and Torres Strait Islander patients.¹⁸ Health professionals supporting Aboriginal and Torres Strait Islander patients managing pain therefore, require communication skills that are suitable for intercultural interactions, with awareness of the different understandings of and responses to illness.^18–20

Ineffective communication may be unrecognized by health professionals, and some health professionals believe that communication skills are inherent or acquired through exposure in the workplace.²¹ Evidence demonstrates, however, that communication training of health professionals improves patient experiences and quality of health care. Communication training has a positive effect on the communication style of health professionals²² and influences patient outcomes.²³ Effective communication has been associated with improved rates of patient recovery, more effective pain control, patient adherence to treatment, and improved psychological functioning.^{22, 24}

Reviews on the educational methods for improving the communication skills of health professionals have demonstrated that experiential learning methods are the most effective. Effective teaching strategies include role play, simulated learning, or supervised practical work.^{25, 26} Pain clinicians have reported that education to improve care for Aboriginal and Torres Strait Islander patients should include communication skills, relevant clinical examples, and show how to blend biomedical knowledge with cultural approaches to improve clinical practice. Health professionals also suggested that an interactive and motivating format, combining activities such as role-play, education, video examples, and individualized feedback and opportunities to apply the learnings would be the preferred format.²⁷

This study reports outcomes, from the perspective of health professionals working in persistent pain management clinics, of a novel education program combining cultural capability and communication skills based on a clinical yarning approach.

Study design and framework

This study is part of a multicentre, single arm interventional feasibility study evaluated using mixed methods, described elsewhere.²⁸ Briefly, the intervention aims to improve cultural capability and communication between health professionals and Aboriginal and Torres Strait Islander patients accessing persistent pain management services in Queensland, Australia. The communication training component was developed, informed by qualitative interviews and focus groups with key stakeholders, and by adapting a patient-centred communication framework, clinical yarning²⁹ for the Queensland context. For the cultural capability component, this study used the cultural capability definition from the Aboriginal and Torres Strait Islander Cultural Capability framework in which ‘cultural capability refers to skills, knowledge, and behaviours that are required to plan, support, improve and deliver services in a culturally respectful and appropriate manner’.³⁰ This project also used experiential and reflective learning approaches to develop the training content and resources aiming to empower participants to identify and challenge the validity of their embedded assumptions and provide the opportunity for interaction in realistic scenarios.³¹

The Clinical Yarning training program was delivered across the study sites sequentially, commencing at site 1, followed by site 2 (a month after site 1), and concluding at site 3 (a month after site 2). The evaluation of the effectiveness of the training involved the analysis of qualitative and quantitative data collected from patients and health professionals. This study presents the analysis of the training evaluation data from health professionals.

Study sites and participants recruitment

This study involved three of the five adult persistent pain clinics in Queensland. These clinics are publicly-funded, hospital-based and provide a combination of inpatient and outpatient pain management services. Aboriginal and Torres Strait Islander patients represent between 4–8% of the total number of patients supported by the three clinics.

Participants were health professionals (medical doctors, nursing staff, allied health, and administrative personnel) working in the three persistent pain management services (two metropolitan and one regional service). Local investigators promoted the training among health professionals during team meetings and via email.

This study was approved by the Townsville Hospital and Health Service Human Research Ethics Committee - reference number 63949, and by respective ethics committees of the study sites. Participation was voluntary and written informed consent was obtained from all participants.

The communication training program and resources

The training format involved two components: cultural capability and clinical yarning and was delivered in a single day, over 7 hours of training, which combined education and interactive activities with simulation patients. For this training four resources were developed: a standard PowerPoint presentation, For this training four resources were developed: a standard PowerPoint presentation, a facilitator’s manual, a learners’ workbook, and video scenarios of communication between clinicians and Aboriginal and Torres Strait Islander patients with pain (please refer to Supplementary Tables S1-S3).

A Torres Strait Islander (XX) senior cultural capability facilitator and research team member led the development of the cultural capability content and the training outline was presented and discussed with the Cultural Capability Network of Queensland Health, which is comprised of cultural capability coordinators and facilitators. The cultural capability component was facilitated by Aboriginal and Torres Strait Islander cultural facilitators. The training session started with the cultural component, in which the cultural facilitator would describe the historical, social, and emotional impact of colonization. In this part of the training session, the importance of culture, protocols, and ways to communicate effectively with Aboriginal and Torres Strait Islander people were highlighted.

The clinical yarning component was co-facilitated by an experienced pain specialist (XX) and research team member (XX), bringing together clinical and cultural expertise. XX was trained about the clinical yarning framework by one of the authors of the clinical yarning framework (XX).

Clinical Yarning is a patient-centred communication framework that re-conceptualizes clinical communication as social, diagnostic, and management yarns.²⁹ Clinical Yarning is a culturally appropriate and patient-friendly approach that promotes trust and better relationships between clinicians and Aboriginal patients. In this component, participants were introduced to the three elements of the clinical yarning framework along with how these can be applied in persistent pain clinics. Participants were encouraged to recall communication experiences with Aboriginal and Torres Strait Islander patients and to identify the communication skills they felt needed to be improved. Next, a series of scenarios involving clinicians and Aboriginal and Torres Strait Islander patients were presented to participants to identify the elements of the clinical yarning framework and effective communication. The final part of the training involved practising the clinical yarning framework with actors simulating Aboriginal and Torres Strait Islander patients.

The resources developed were relevant to persistent pain management and for the Queensland contexts (Supplementary Tables S1-S3).

Data collection

Following the training, participants completed a retrospective pre-post evaluation questionnaire to evaluate the training (Supplementary Table 6).³² Participants rated pre and post-training perceived importance of communication training, and their perceived knowledge, ability, and confidence to communicate effectively with Aboriginal and Torres Strait Islander patients. The evaluation questionnaire included three sections with closed-ended questions plus two open-ended questions. The separate sections included questions about 1) demographic characteristics and previous training; 2) assessment of communication skills and cultural awareness; and 3) satisfaction with training.

The first section included demographic characteristics and location (i.e. study site, profession, age, sex, and Indigenous status), participation in previous cultural training (Yes/No), and types of training received. The second section included communication skills and cultural awareness in which health professionals rated their perceived importance of communication training when working with Aboriginal and Torres Strait Islander patients, and their perceived knowledge, ability, and confidence when communicating with Aboriginal and Torres Strait Islander patients with persistent pain (1 = very low to 5 = very high).

Satisfaction with training was assessed through twelve questions rated on a five-point Likert scale (1 = strongly disagree to 5 = strongly agree) 1) if the planned objectives were met; 2) if the issues were dealt with in-depth as the length of the course allowed; 3) the length of the course was adequate for the objectives and content; 4) if the method was well suited to the objectives and content; 5) if the method enabled participants to take an active part in the training; 6) if the training enabled the participant to share professional experiences with colleagues; 7) if the training was realistic and practical; 8) if the training context was well suited to the training process; 9) if the training received was useful for their job; 10) if the training received was useful for personal development; 11) if the training merits a good overall rating, and 12) if participants would recommend the program to others. In addition, two open-ended questions provided the opportunity for participants to indicate ‘what did you find most useful?’ and ‘how could the program be improved?’.

Data analysis

Descriptive statistics were used to summarize participants’ demographic characteristics, location, and previous training. Categorical variables, such as ratings of the perceived importance of communication training for working with Aboriginal and Torres Strait Islander patients; perceived knowledge, ability, confidence; and satisfaction with training were summarized using frequencies and percentages for each categorical variable. Participant responses were then grouped as ‘highly’ when participants rated statements with scores of 4–5. The training program was described using mean, standard error (SE), and 95% confidence interval (95% CI). Change in mean scores of the perceived importance of communication training for working with Aboriginal and Torres Strait Islander patients; perceived knowledge, ability, and confidence between pre and post-training were evaluated with paired samples t-tests. The difference of pre and post-training means between study sites was tested using one-way ANOVA and Tukey HSD post hoc test was used to identify the study site driving the difference. Statistical significance was set at alpha = 0.05. The Cohen’s effect size³³ for the difference between mean scores was calculated as follows:

The responses to the open-ended questions were quantified and analysed thematically.³⁴ Two authors (XXX and XX) independently read the responses and generated initial codes searching for themes. Next, the identified themes were reviewed, discussed, agreed upon, and presented as frequencies further illustrated with quotes.

Participants’ demographic characteristics and previous cultural training

Of the 111 health professionals working across the three clinics at the time of the training delivery, 57 participated in the training (51% participation rate) and 51 of them completed a training evaluation questionnaire (90% response rate) (Table 1). In total 77% of participants were female, with an average age of 39 years (SD=9.69) of age and 98% were of non-Indigenous background. Almost a third of participants were medical doctors (29%) and three-quarters of all participants reported having previous cultural training (75%). The most frequent training types reported by health professionals were the mandatory cultural awareness training provided by Queensland Health (55%), and training during university studies (29%).

Table 1

Health professionals’ demographic characteristics and previous training.

Demographic characteristics and previous training	N= 51
Demographic characteristics and previous training	n	%

Study site
Metropolitan (A)	13	26
Regional	24	47
Metropolitan (B)	14	28

Age¹
21 - 40 years	33	65
41 - 60 years	11	22
61 - 80 years	3	6

Sex
Male	12	24
Female	39	77

Indigenous status
Aboriginal and Torres Strait Islander	1	2
Non-Indigenous	50	98

Profession
Medical doctors (pain medicine specialist, registrar and psychiatrist)	15	29
Nursing Staff (registered nurse, clinical nurse, nurse navigator, enrolled nurse)	13	26
Physiotherapist	6	12
Psychologist	6	12
Pharmacist	2	4
Occupational Therapist	6	12
Administrative staff	3	6

Previous cultural training
Yes	38	75
No	13	26

If previous cultural training - type of training²
Hospital based mandatory cultural awareness training/education packages	23	55
Cultural capability and safety lectures during university studies	12	29
Primary school cultural awareness training	1	2
Training for foster care	1	2
Not specified/unknown	5	12

1 Four missing values

2 Participants could indicate more than one option of training

Training evaluation ratings

As shown in Figure 1 and Table 2, there was a significant increase in the mean scores for the four items measured. The perceived importance of communication training increased from pre-training (Mean=4.18; 95% CI= 3.91-4.44) to post-training (Mean=4.69; 95% CI=4.52-4.85) (p>0.001). There were also significant improvements of reported by health professionals in their knowledge (pre-training Mean=2.94; 95% CI= 2.74-3.14), ability (pre-training Mean=2.96; 95% CI= 2.79-3.13) and confidence (pre-training Mean=2.96; 95% CI= 2.75-3.17) compared to post-training (Mean=3.98; 95% CI= 3.81-4.15; Mean=3.96; 95% CI= 3.80-4.12; Mean=4.02; 95% CI= 3.85-4.19, respectively) (p>0.001). The most marked increase was health professionals’ perceived confidence (Table 3).

Table 2

Pre and post-training mean score (95% CI) (N=51).

Items	Pre-training		Post-training
Items	Mean	(95% CI)	Mean	(95% CI)
Importance	4.18	(3.91 - 4.44)	4.69	(4.52 - 4.85)
Knowledge	2.94	(2.74 - 3.14)	3.98	(3.81 - 4.15)
Ability	2.96	(2.79 - 3.13)	3.96	(3.80 - 4.12)
Confidence	2.96	(2.75 - 3.17)	4.02	(3.85 - 4.19)

Table 3

Comparison between pre and post-training rating mean (SE) of perceived importance, knowledge, ability and confidence to communicate (N=51)

Items	Pre-training		Post-training		Difference between Means	(SE)	Cohen’s D Effect size	p
Items	Mean	(SE)	Mean	(SE)	Difference between Means	(SE)	Cohen’s D Effect size	p
Importance	4.18	(0.13)	4.69	(0.08)	0.66	0.09	0.66	<0.001
Knowledge	2.94	(0.10)	3.98	(0.09)	1.57	0.09	1.57	<0.001
Ability	2.96	(0.08)	3.96	(0.08)	1.72	0.07	1.72	<0.001
Confidence	2.96	(0.11)	4.02	(0.09)	1.55	0.08	1.55	<0.001

*Paired-samples t-test, df=50

Training evaluation and demographic characteristics

Following training, fewer younger health professionals (≤40 years) highly rated their perceived importance of communication training (91% vs 100%), and their perceived knowledge (76% vs 86%), and ability (79% vs 86%) to communicate effectively with Aboriginal and Torres Strait Islander people compared to health professionals aged ≥41 years. In turn, younger health professionals highly rated more frequently to be confident to communicate effectively with Aboriginal and Torres Strait Islander patients (85% vs 71%) (Table 4). A higher proportion of male health professionals highly rated their perceived importance of communication training (100% vs 92%), their perceived knowledge (92% vs 77%), and confidence (92% vs 80%) to communicate with Aboriginal and Torres Strait Islander people compared to female health professionals.

Medical doctors highly rated their ability and confidence to communicate (93% vs 85%) more frequently than nursing staff. However, nursing staff highly rated the perceived importance of communication training (100% vs 93%) and their perceived knowledge (85% vs 80%) more often than medical doctors. In comparison to other health professionals, a lower proportion of psychologists and physiotherapists highly rated their perceived importance of communication training (83% for both groups), perceived knowledge (67% for both groups), and ability (50% and 67%, respectively) to communicate with Aboriginal and Torres Strait Islander people. Health professionals who had received previous cultural training gave higher ratings across all four items: the perceived importance of training (100% vs 92%), their perceived knowledge (82% vs 77%), ability (87% vs 69%), and confidence (84% vs 77%).

Table 4

Demographic characteristics and previous training of health professionals who rated high or very high (scores 4-5) the perceived importance for training, knowledge, ability and confidence to communicate with Aboriginal and Torres Strait Islander patients

Demographic characteristics and previous training	n	Importance of training				Knowledge of how effectively to communicate				Ability to communicate				Confidence to communicate
	n	Pre-training		Post-training		Pre-training		Post-training		Pre-training		Post-training		Pre-training		Post-training

Study site		n	(%)	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)
Metropolitan A	13	8	(62)	10	(77)	4	(31)	10	(77)	2	(15)	10	(77)	3	(23)	9	(69)
Regional B	24	19	(79)	24	(100)	3	(13)	21	(88)	3	(13)	22	(92)	4	(17)	22	(92)
Metropolitan C	14	10	(71)	14	(100)	3	(21)	10	(71)	3	(21)	10	(71)	4	(29)	11	(82)

Age¹
21 - 40 years	33	22	(67)	30	(91)	7	(21)	25	(76)	7	(21)	26	(79)	8	(24)	28	(85)
41 - 60 years	11	8	(73)	11	(100)	1	(9)	9	(82)	0	(0)	9	(82)	2	(18)	7	(64)
61 - 80 years	3	3	(100)	3	(100)	1	(33)	3	(100)	1	(33)	3	(100)	1	(33)	3	(100)

Sex
Male	12	10	(83)	12	(100)	3	(25)	11	(92)	3	(25)	10	(83)	5	(42)	11	(92)
Female	39	27	(69)	36	(92)	7	(18)	30	(77)	5	(13)	32	(82)	6	(15)	31	(80)

Indigenous status
Indigenous	1	0	(0)	0	(0)	1	(100)	1	(100)	1	(100)	1	(100)	1	(100)	1	(100)
Non-Indigenous	50	37	(74)	48	(96)	9	(18)	40	(80)	7	(14)	41	(82)	10	(20)	41	(82)

Profession
Medical doctors	15	10	(67)	14	(93)	4	(27)	12	(80)	3	(20)	14	(93)	5	(33)	14	(93)
Nursing Staff	13	10	(77)	13	(100)	3	(23)	11	(85)	2	(15)	11	(85)	3	(23)	11	(85)
Physiotherapist	6	3	(50)	5	(83)	1	(17)	4	(67)	1	(17)	4	(67)	1	(17)	5	(83)
Psychologist	6	5	(83)	5	(83)	1	(17)	4	(67)	2	(33)	3	(50)	2	(33)	5	(83)
Pharmacist	2	1	(50)	2	(100)	1	(50)	2	(100)	0	(0)	2	(100)	0	(0)	1	(50)
Occupational T.	6	5	(83)	6	(100)	0	(0)	5	(83)	0	(0)	5	(83)	0	(0)	3	(50)
Administrative	3	3	(100)	3	(100)	0	(0)	3	(100)	0	(0)	3	(100)	0	(0)	3	(100)

Previous cultural training
Yes	38	29	(76)	35	(100)	8	(21)	31	(82)	7	(18)	33	(87)	10	(26)	32	(84)
No	13	8	(61)	13	(92)	2	(15)	10	(77)	1	(8)	9	(69)	1	(8)	10	(77)

1 Four missing value

Training evaluation by study site

Comparing study sites, the mean scores were similar for perceived importance of communication (F(2,48)= 0.448; p=0.641) and perceived ability ((F(2,48)= 3.645; p=0.075) (Figure 2). However, study sites differed in relation to pre-post training improvements of perceived knowledge (F(2,48)= 2.731; p=0.034) and confidence (F(2,48)= 4.724; p=0.013). A Tukey post hoc test showed that the Metropolitan site (B) and the regional site had similar increases in knowledge (1.21 and 1.17 respectively; p=0.975). However, when comparing the perceived knowledge of Metropolitan site (A) to the Regional site there was a smaller increase (0.62; p=0.048). The regional site reported a significant increase in mean score for confidence to communicate effectively with Aboriginal and Torres Strait Islander patients (1.29) compared to metropolitan site A (0.69; p=0.010) but not for Metropolitan site B (1.0; p=0.293).

Satisfaction with training and suggested program improvements

Overall, of the 12 items about training satisfaction, a high proportion of health professionals (range 94%-100%) (Table 5 and Supplementary Table 4) agreed or strongly agreed that the training met the objectives, issues were dealt with in-depth; the course length was adequate; the method suited the objectives, the method enabled the participant to take an active part in the training, the training enabled to share professional experiences, the training was a realist and practical, the training context was well suited to the training process the training received is useful for their job, the training is useful for the professional development the training merits a good overall rating and they would recommend the program to others. The item with the highest proportion of undecided participants was the ‘length of the course was adequate’ (n=3; 6%) and the only item for which a participant disagreed with the statement was ‘I would recommend this program to others’ (n=1; 2%).

Among the professions, a lower proportion of administrative staff agreed or strongly agreed that the length of the training was adequate and that the training received was useful for their job (67%) compared to the other professions (83-100%). Only half of the administrative staff agreed or strongly agreed that the training enabled sharing professional experiences compared to 83-100% among the other professions.

Forty-two health professionals (n=42/51; 82%) responded to the open-ended question indicating what were the most useful aspects of the training and four themes were identified from the responses: 1) sharing of historical and cultural knowledge, 2) interactive simulation of case scenarios with feedback provided by the Aboriginal and Torres Strait Islander simulation patients, 3) the framework and communication content, and 4) examples of cases from the pain management setting and having experienced facilitators in pain management and cultural capability (Supplementary Table 5 – Quotes to illustrate the themes identified).

Half of all participants reported that the historical and cultural knowledge shared by Aboriginal and Torres Strait Islander cultural facilitators (n=21; 50%) was the most useful aspect of the training. These facilitators provided insightful information about the impact of colonization on Aboriginal and Torres Strait Islander health and well-being. Health professionals reported being able to reflect upon the feelings of Aboriginal and Torres Strait Islanders, especially in approaching government institutions, including healthcare, and communicating with non-Indigenous staff.

The interactive module with role-playing patients and with feedback provided by the Aboriginal and Torres Strait Islander simulation patients was rated the most useful aspect by 16 participants (38%). Participants reported particularly valuing feedback and interpretation of Aboriginal and Torres Strait Islander people, verbal and non-verbal cues, and helping to contextualize the information provided. These elements were described as unique opportunities afforded by this training.

The framework and communication content was rated as the most useful aspects by 9 participants (21%). These participants reported that it was important to learn how the different components of the framework could be applied. For example, participants highlighted the usefulness of the explanation about the social yarn which was viewed as crucial to building rapport with Aboriginal and Torres Strait Islander patients.

Three participants (7%) rated pain-specific cases and the experienced facilitators as the most useful aspect. These participants highlighted how they felt engaged throughout the training day. They reported that they could relate to the simulated patients in the pain setting and the questions arisen were answered and discussed having the input of an experienced pain specialist and supported by the cultural facilitator.

Eleven participants (22%) suggested improvements to the training program by extending the training time (n=3; 27%); including follow-up and feedback (clinicians and patients) to enable problem-solving and consolidate lessons learned (n=3; 27%); adopting a stronger focus on the management yarning, more content about the local history including people from inland as well as coastal areas (n=3; 27%) and more opportunities for yarning and group discussions (n=2; 18%).

Table 5

Demographic characteristics and previous training of health professionals who agreed or strongly agreed (scores 4-5) with the statements about their satisfaction with CY training

Demographic characteristics and previous training	Objectives were met		Issues were dealt with depth		Course length was adequate		The method was well suited		Method enabled active participation in the training		Training enabled sharing professional experiences¹		Training was realist and practical		Training context was well suited to the training process		Training received is useful for my job¹		Training received is useful for personal development		Training merits overall good rating		I would recommend this program to others

Study site	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)
Metropolitan(A)	12	(92)	13	(100)	12	(92)	13	(100)	13	(100)	13	(100)	12	(92)	13	(100)	11	(85)	12	(92)	13	(100)	12	(92)
Regional(B)	24	(100)	24	(100)	22	(92)	24	(100)	24	(100)	22	(96)	23	(96)	24	(100)	23	(100)	23	(96)	24	(100)	24	(100)
Metropolitan(C)	14	(100)	14	(100)	14	(100)	14	(100)	14	(100)	13	(93)	14	(100)	14	(100)	14	(100)	14	(100)	14	(100)	14	(100)

Age²
21 - 40 years	32	(97)	33	(100)	31	(94)	33	(100)	33	(100)	32	(100)	33	(97)	33	(100)	30	(94)	32	(97)	33	(100)	32	(97)
41 - 60 years	11	(100)	11	(100)	10	(91)	11	(100)	11	(100)	9	(82)	11	(100)	11	(100)	11	(100)	10	(91)	11	(100)	11	(100)
61 - 80 years	3	(100)	3	(100)	3	(100)	3	(100)	3	(100)	3	(100)	3	(100)	3	(100)	3	(100)	3	(100)	3	(100)	3	(100)

Sex
Male	12	(100)	12	(100)	12	(100)	12	(100)	12	(100)	12	(100)	12	(100)	12	(100)	12	(100)	12	(100)	12	(100)	12	(100)
Female	38	(97)	39	(100)	36	(92)	39	(100)	39	(100)	36	(95)	37	(95)	39	(100)	36	(95)	37	(95)	39	(100)	38	(97)

Indigenous status
Indigenous	1	(100)	1	(100)	1	(100)	1	(100)	1	(100)	1	(100)	1	(100)	1	(100)	0	(0)	0	(0)	1	(100)	0	(0)
Non-Indigenous	49	(98)	50	(100)	47	(94)	50	(100)	50	(100)	47	(96)	48	(96)	50	(100)	48	(98)	49	(98)	50	(100)	50	(100)

Profession
Medical doctors	15	(100)	15	(100)	15	(100)	15	(100)	15	(100)	15	(100)	15	(100)	15	(100)	15	(100)	15	(100)	15	(100)	15	(100)
Nursing Staff	13	(100)	13	(100)	12	(92)	13	(100)	13	(100)	13	(100)	12	(100)	13	(100)	13	(100)	13	(100)	13	(100)	13	(100)
Physiotherapist	5	(83)	6	(100)	6	(100)	6	(100)	6	(100)	6	(100)	5	(83)	6	(100)	5	(83)	6	(100)	6	(100)	6	(100)
Psychologist	6	(100)	6	(100)	6	(100)	6	(100)	6	(100)	6	(100)	6	(100)	6	(100)	5	(83)	5	(83)	6	(100)	5	(83)
Pharmacist	2	(100)	2	(100)	2	(100)	2	(100)	2	(100)	2	(100)	2	(100)	2	(100)	2	(100)	2	(100)	2	(100)	2	(100)
Occupational T.	6	(100)	6	(100)	5	(83)	6	(100)	6	(100)	5	(83)	6	(100)	6	(100)	6	(100)	6	(100)	6	(100)	6	(100)
Administrative	3	(100)	3	(100)	2	(67)	2	(100)	3	(100)	1	(50)	3	(100)	3	(100)	2	(100)	2	(67)	3	(100)	3	(100)

Previous cultural training
Yes	37	(97)	38	(100)	35	(92)	38	(100)	38	(100)	35	(95)	36	(95)	38	(100)	35	(95)	36	(95)	38	(100)	37	(97)
No	13	(100)	13	(100)	13	(100)	13	(100)	13	(100)	13	(100)	13	(100)	13	(100)	13	(100)	13	(100)	13	(100)	13	(100)

Training enabled sharing professional experiences’ and ‘Training received was useful to my job’ had 1 missing value for the following characteristics: study site, sex, Indigenous status, profession and previous training Within age group all the items had 4 missing values; except, ‘Training enabled sharing professional experiences’ and study site and ‘Training received was useful to my job’ had 5 missing values

To our knowledge, this is the first study to evaluate a communication skills training program that combines cultural capability and a clinical yarning framework and contextualises these to the persistent pain setting. Persistent pain has a greater burden on Aboriginal communities^{16, 17, 35} (to date scarce evidence is available about the burden to Torres Strait Islander people but is likely to be significant), and therefore persistent pain services need to consider how to address this need. Ensuring cultural sensitive staff and suitable communication skills are essential to provide optimal care.³⁶

The broader project within which this study occurred demonstrated that involving stakeholders in the development of the training²⁸ and the partnership of researchers with cross-disciplinary²⁸ expertise was an important approach to achieve high satisfaction among participants. In the initial stages of this study, clinicians participating in focus groups²⁷ reported that there was a need for cultural knowledge and how cultural factors could be integrated into clinical practice. Additionally, the combination of cultural capability and the clinical yarning framework used to adapt the doctor-patient communication style was well accepted and endorsed for future communication training. Ratings indicate that the training improved participants’ perceptions about the importance of communication training, and their perceived knowledge, ability, and confidence to communicate effectively with Aboriginal and Torres Strait Islander patients. Particularly relevant to the communication between health professionals and Aboriginal and Torres Strait Islander patients was the significant increase in participants’ perceived confidence. While the findings of improvements in perceived knowledge, ability, and confidence after communication skills training are not unique to this study, these findings are relevant because evidence suggests that achieving improvements across all three of these domains is required for change in practice.³⁷ According to Bandura,³⁸ it is not enough for individuals to possess knowledge and skills to perform a task, they must also believe they can successfully perform that task, even in challenging circumstances.³⁹ The current study finds the training meets these criteria.

Another important contribution of this study is the strong endorsement of the experiential and reflective learning approaches adopted in the training. This is consistent with the principles of Adult Learning Theory that underpin continuing professional development training.³¹ The experimental component was contextualized to the clinical setting of pain management and promoted the interaction of Aboriginal and Torres Strait Islander simulated patients and clinicians, creating the opportunity for self-reflection through the feedback from simulated patients.

Health professionals have an important role in influencing patient experiences.^{40, 41} In this study, medical doctors perceived their ability and confidence to communicate effectively with Aboriginal and Torres Strait Islander people more highly than the other health professionals. In contrast, nursing staff perceived the importance of training and knowledge as high but indicate lower ability and confidence. These results may demonstrate the efforts of medical schools to introduce interviewing techniques and communication skills training in school curricula.^{42, 43} Alternatively, it could reflect an overestimation by doctors of their ability to communicate effectively with these patient groups. Gude et al⁴⁴ demonstrated that medical students and young physicians did not realistically and reliably assess their self-efficacy regarding communication skills. It was found that there was a significant discrepancy between self-rated communication ability and the communication experts’ ratings.⁴⁴ Furthermore, the differences across professional groups may suggest that it is important to consider disciplinary norms and needs when planning communication training. Academic disciplines are communities with their language, norms, and values. Each discipline develops a disciplinary communication competence so that its members share a common understanding of appropriate ways of communicating and behaving and enabling the interaction between members of the disciplinary culture effectively.⁴⁵

Health professionals from predominantly Western cultures were trained about Aboriginal and Torres Strait Islander history, beliefs, values, and worldviews and how these influenced their communication at a group level. The research team had Aboriginal and Torres Strait Islander researchers involved in every stage of the study development, from the leadership down to the implementation and evaluation of the study. In this intercultural communication program, health professionals were stimulated to reflect on their understanding of how patients may express their pain and how they could engage with patients. From the qualitative evaluation, participants identified the need for more cultural local knowledge and understanding of the different language protocols used by Aboriginal and Torres Strait Islander patients.

Health professionals appreciated the opportunity to interrogate cultural questions, in a safe setting and with Aboriginal and Torres Strait Islander people providing feedback to them. The training session was considered very informative and health professionals suggested further training with a greater focus on the language and terminology used by Aboriginal and Torres Strait Islander people to describe and express pain. Further work is needed to understand how this training is embedded in practice that is, what effect training has on clinical practice and what impact this has on patient care and outcomes.

Limitations of the study include the small sample size of clinicians involved in the training and the self-reported measures of knowledge, ability, and confidence Metropolitan site A was the first site to receive the training and this perhaps has affected the delivery of training and the reported improvements. While three of the five persistent pain services in Queensland were included in the study, not all professional categories were represented (e.g. addiction medicine specialists and General Practitioner). Although this study indicates that training participants developed the perceived knowledge, ability, and confidence to effectively communicate with Aboriginal and Torres Strait Islander patients, it remains unclear whether they were able to put this training into practice.

This patient-centred communication training, delivered through a novel model that combines cultural capability and the clinical yarning framework applied to the pain management setting, was highly acceptable and significantly improved participants’ perceived competence. The training provided an opportunity for health professionals to reflect on their intercultural communication practice stimulated by theoretical elements of the clinical yarning framework and interaction with simulated patients and cultural feedback. The impact of the training in clinical practice is still to be demonstrated and reinforcement of the learnings was suggested by participants. This method is transferrable to other health system sectors seeking to train their clinical workforce with culturally sensitive communication skills.

Author’s contributions: GP, CMB, SE, SB, RM, MB, JI, PG, JPK, IL: conceptualization. CMB, KH, CJ, AC, PG, JPK, MB, MT: data collection. CMB, SE, SB, RM, GP, AC, EM, IL: formal analysis. CMB, GP, SE, SB, RM, MB, JI, PG, JPK, IL, KH: methodology. CMB, SE, SB, RM, IL, AC, GP: writing original draft. CMB, SE, SB, RM, MB, JI, PG, JPK, IL, GP, EM: writing review and editing. All authors have read and approved the final version of the manuscript.

Acknowledgements: The research team would like to thank the clinicians and the Indigenous Liaison Hospital Officers from the three study sites who were essential for the conduct of this study.

Ethics approval and consent to participate: This study was approved by a Queensland Hospital and Health Service Human Research Ethics Committee - the Townsville Hospital and Health Service Human Research Ethics Committee - reference number 63949, and by respective ethics committees of the study sites (Royal Brisbane and Women's Hospital Human Research Ethics Committee and Metro South Health Service District Human Research Ethics Committee). This work was carried out in accordance with relevant guidelines and regulations.

Written informed consent to participate in the study was obtained from all participants.

Consent for publication: Not applicable

Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding: This study was funded by Brisbane Diamantina Health partners (BDHP) – Medical Research Future Fund (MRFF): Rapid Applied Research Translation (RART) Grant Opportunity.

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No competing interests reported.

Yarning about pain: evaluating communication training for health professionals at persistent pain services in Queensland, Australia

Status:

Version 1

Abstract

Figures

1. Introduction

2. Methods

Study design and framework

Study sites and participants recruitment

The communication training program and resources

Data collection

Data analysis

3. Results

4. Discussion

5. Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1