This is a multi-component intervention with three main aims (Table 1) guided by implementation science approaches (Table 2). Major components of the intervention, described using the TIDieR Checklist (Template for Intervention Description and Replication) [23] (Supplementary Table), are: cultural safety training, a community of practice of Cultural Safety Champions, employment of and training for interpreters, and advocacy strategies for cultural change within health systems to provide more fit-for-purpose care for the majority First Nations patients.
Table 1
The Communicate Study Partnership Aims
Aim 1: Transform the culture of healthcare systems to achieve excellence in providing culturally safe care for First Nations peoples
a. Develop, implement and evaluate anti-racism training using ‘Ask the Specialist Plus’. This comprises moderated discussion and reflection on ‘Ask the Specialist’ podcast episodes held during in-service and clinical teaching timeslots for healthcare providers
b. Create a community of practice of culturally safe clinicians supported by a social media chat group and seminars provided by invited experts
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Aim 2: Strengthen the tools and strategies required underpinning culturally safe practice
a. Improve demand for Aboriginal interpreters and Aboriginal health practitioners through improved knowledge of language diversity and cultural safety, and recognition of patient needs
b. Improve supply of interpreters and Aboriginal health practitioners willing to work in the hospital environment by creating a culturally safe workplace and supporting career pathways
c. Tailor effectiveness strategies to participating sites such as
- positioning interpreters at points of need and embedding them in medical and surgical teams
- Optimising workflow to facilitate efficiency and availability across hospital departments
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Aim 3: Evaluate outcomes using comprehensive qualitative and quantitative measures
a. Qualitative enquiry to assess cultural safety from patient perspectives, and understand experiences of Aboriginal and non-Aboriginal healthcare providers and interpreters
b. Quantitative outcomes including:
- performance across key indicators: changes in documentation of language; interpreter bookings made; interpreter bookings completed; % Aboriginal patients in need getting access to an interpreter
- Impact of intervention: proportion of admissions with and without interpreters ending in self-discharge; unplanned re-admissions and changes in hospital length of stay
- economic analysis of the costs and cost benefits of interpreter use to decrease self-discharge and re-admission rates.
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Table 2
Methodological approaches used in the Communicate Study Partnership
Category
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Philosophical theories
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Implementation theory
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Determinant framework
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Process models
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Evaluation
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Specific approaches
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- Cultural safety
- Critical race theory
- Freirean pedagogy
- Whiteness studies
- Decolonising theory
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- Behaviour change wheel
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- Supply-demand-efficiency-effectiveness cycle
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- Participatory action research
- Continuous quality improvement
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- RE-AIM
- Kirkpatrick model of learning
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Description
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Together, these provide philosophical and ethical guidance
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Describes the breadth of interventions needed for successful behaviour change among healthcare providers
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Describes the elements required to improve uptake of interpreters, where supply refers to interpreter availability, demand and effectiveness refer to healthcare provider behaviours and capabilities, and efficiency relates to systems factors
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These methods guide translation of research into practice, using a participatory approach: pro-active engagement of relevant front line and executive staff from health and interpreter services with data to motivate improvement in cultural safety performance indicators
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Provides a structured way to critique the program to summarise successes, failures and learnings
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Rationale for choice of specific approach
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Appropriate to the subject matter of First Nations healthcare in the predominant White Australian health system context
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This project focuses on changing the behaviours of healthcare providers and changing institutional culture
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These are the determinants we hypothesise will influence success in delivering culturally safe care and other implementation outcomes
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This approach will support long term sustainability
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These are both validated, pragmatic ways to report overall program outcomes and training outcomes respectively
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Artwork to depict the intentions of the study has been provided by Larrakia artist Jason Lee (Fig. 1). Lee states: "The two hands represent the relationship between doctor and patient. The inner ring represents Menzies and the community and male and female patients."
Design
This project devises, supports and evaluates system-strengthening activities at health service and interpreter service levels. In summary, a multi-component intervention will be implemented over 4 years. Impact over time will be evaluated longitudinally using data collected during baseline periods prior to activity implementation, and study implementation periods. The study has a baseline period (July 1 2020 - June 30 2022) for the purposes of quantitative and some qualitative data collection as detailed below, and a study activity period (July 1 2022 - June 30 2026); Fig. 2. Additionally, individual before-and-after time frames for qualitative data collection will allow for comparison of impacts of training before and after implementation of sequential training sessions run during 2023–2026 for individual hospital units or teams.
Impact of the activities will be assessed using mixed methods. In summary, quantitative outcomes will be measured using time-series analysis; qualitative measures of patient and provider interactions and experience will be examined over the course of the study (Table 1 and details below). A continuous quality improvement (CQI) approach [24, 25] will ensure that data are used pro-actively, through participatory methods that engage and motivate relevant front line and executive staff from health and interpreter services. There are co-primary qualitative and quantitative outcome measures (Table 3): cultural safety, as experienced by First Nations peoples treated at participating hospitals, and proportion of admitted First Nations patients who self-discharge.
Table 3
Outcome measures, data sources and analytical approach
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Outcome measure
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What does this capture?
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Data source
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Analysis
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Quantitative
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Documentation of language
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Health system quality, safety, efficiency
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Electronic medical records
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Time series analysis
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Documentation of interpreter need in patient records
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Interpreter bookings made
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Healthcare provider behaviour
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Linked Admitted Patient Care (APC) and Aboriginal Interpreter Service (AIS) dataset
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Interpreter bookings completed
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System efficiency and interpreter willingness
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% Aboriginal patients in need* getting access to an interpreter
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Combination of the above
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Self-discharge
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Patient health outcome
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Unplanned re-admission
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Health system cost
Patient health outcome
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Hospital length of stay
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Health system cost
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Survey data
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Surveys after participating in each session of ‘Ask the Specialist Plus’
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Value of training and appropriateness of podcast format
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Surveys to assess reaction to training, skills obtained, application, benefit
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Descriptive summary data
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Count of NT Health interpreters and AHPs employed and retained; turnover in role during the 5 years of the study; languages represented
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Quality of support for Aboriginal staff; institutional cultural safety
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NT Health employment records
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Annual report of descriptive summary data
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NAATI certification status of interpreters – % having attained level 1, 2, 3 or full certification
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Effectiveness of interpreter training
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AIS records
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Annual report of descriptive summary data
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Qualitative
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Cultural safety as experienced by First Nations Australian people managed at participating health services
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Effectiveness of activities as perceived by practitioners and recipients of care
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Interviews and observational data
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Narrative analysis
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Healthcare provider experience
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Interpreter / Aboriginal Health Practitioner experience
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*Proportion of Aboriginal patients in need of an interpreter Community consultation indicates that most people who speak an Aboriginal language as their first language would benefit from an interpreter in healthcare interactions; some advise an opt-out approach, offering an interpreter for anyone with an Aboriginal first language (podcast episode 2[56]). We conservatively estimate 50% of Aboriginal patients would benefit from an interpreter. This project will provide better estimates of the true proportion.
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Overarching program evaluation will use the RE-AIM model (Reach, Effectiveness, Adoption, Implementation, Maintenance – Table 4) [26]. This framework is a well-validated evaluation tool that promotes sustainability and generalisability.
Table 4
‘Ask the Specialist Plus’ training program weekly discussion topics
Week
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Topic
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Format
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1
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Introduction to cultural safety
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1 hour facilitated discussion
Slide presentation developed to support consistency in approach between different facilitators
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2
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Get to know your patient
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Listen to podcast episode in own time then participate in 1 hour facilitated discussion with slide presentation
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3
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Communicating with your patient
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4
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Communicating with interpreters
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5
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Patient centred care
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6
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Informed consent
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7
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Recognising and addressing racism
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8
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Perspectives on health and wellbeing
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Ethical considerations
Regarding terminology, we use First Nations which recognises the diversity of nations who hold unceded sovereignty over the land and waters referred to as Australia. When required, we also use the term Aboriginal as per stakeholder naming conventions such as the Aboriginal Interpreter Service and in line with this where required, to describe First Nations languages and language interpreters. We use the term White where appropriate for non-Indigenous 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 - or White - in comparison to marginalised people [27, 28].
Partnership model
Participating sites are hospitals in the ‘Top End’ region of the Northern Territory of Australia: Royal Darwin Hospital (RDH), Katherine Hospital (KH) and Gove District Hospital (GDH).
This project was funded by the Australian National Health and Medical Research Council as a Partnership Grant on the basis of collaborating organisations bringing financial and in-kind support to the implementation of the project. Partner organisations are Menzies School of Health Research (Menzies; the host organisation), the Northern Territory Government Health Department (NT Health), the Northern Territory Aboriginal Interpreter Service (AIS) and the National Accreditation Authority for Translators and Interpreters (NAATI). Additional funding was obtained from the Medical Research Futures Fund of Australia. Underpinning this partnership model, this project uses Participatory Action Research (PAR) [29] in which stakeholders, participants and researchers collaborate to develop and enact real world solutions to complex problems within Top End Northern Territory hospitals. To implement a PAR project, researchers and participants reflect on the issues they face, and collaborate to transform problems that perpetuate inequities; the hierarchical relationship between researcher and participant is replaced by reciprocity, trust and shared power [29]. PAR projects value the experiential knowledge of marginalised peoples and the model is increasingly used in health research with First Nations communities internationally [30].
The Australian National Safety and Quality Health Service (NSQHS) outlines standards by which health services should operate. Standard 2 (‘Partnering with Consumers’) and Standard 6 (‘Communicating for safety’) are represented by committees which guide the implementation of these standards at NT Health. The Communicate Study partnership reports regularly to these committees, and is organisationally located within the NT Health Aboriginal Health Committee.
Philosophical frameworks and research theory
Relevant decolonising philosophies informing project design include cultural safety [13, 14], Critical Race Theory [31] and Freirean pedagogy [16]. Cultural safety is the provision of an environment and practices that are safe for peoples of all ethnicities. It is akin to anti-racism, “about the analysis of power and not the customs and habits of anybody” [14]. 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: 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.[14, 16, 31] 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 patients 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 being a strategy to dismantle racist thinking [32]) 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 [33]. 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 [34].
The Freirean concept of “problem posing education” [16] has directly 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 hypothesized 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 [35]. This model was used to develop the Ask the Specialist podcast and the health training for hospital-based interpreters.
Implementation theories and frameworks
Implementation theories, models and frameworks are summarised in Table 2. The ‘COM-B’ system (capability, opportunity, motivation) informs study activities, recognising that these attributes are central to achieving behaviour change [36]. 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 highly relevant determinant framework of interpreter uptake [37]. 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, and about the names of those languages, and about how to access interpreters (capability and opportunity). Efficiency is achieved through streamlined bookings 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 continuous quality improvement (CQI) that builds comprehensively on the plan-do-study-act cycle [38]. 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. The quarterly meetings will be an opportunity to identify and troubleshoot barriers and implement sustainable improvements through the partnership model with the relevant service providers.
Activities to be implemented to address each aim
Activities are summarised in the Template for Intervention Description and Replication (TIDieR) checklist [23] (Supplementary Table) and are described here in relation to each aim (Table 1).
Achieve excellence in providing culturally safe care
Aim 1 is to transform the culture of healthcare systems to achieve excellence in providing care for First Nations people. 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 program developed by the Communicate Study team to promote anti-racism within Northern Territory hospitals. It is an 8-week program based on the ‘Ask the Specialist’ podcast [39]. The ‘Plus’ refers to the added activities to support critical reflection on the contents of the podcast. Participants are asked to pre-listen to a podcast episode (< 18 minutes) then attend a 1-hour small-group facilitated discussion with a topic focus (Table 4) during the team’s usual weekly teaching slot - often lunchtime or early morning. Group size is preferably less than 25 participants to encourage participation and sharing of ideas in a safe, supportive environment. Facilitators can make use of materials and slides prepared by VK and SYM 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 program was piloted in 2021 in the Royal Darwin Hospital’s Department of Women and Children’s Health, and Endocrinology departments, demonstrating feasibility and acceptability of the training program’s mode and timing of delivery and content. Preliminary findings from feedback surveys indicated high satisfaction and a request for more such training (unpublished).
Staff who attend the training will also receive a cultural safety communication checklist which will be printed and laminated (8cm by 8cm square) to be attached to their staff identification lanyards (Box). The checklist was inspired by work undertaken with clinicians in New South Wales, Australia, [40] who identified the need to have a self-assessment checklist to guide their practice with First Nations families. Our team adapted the checklist for use in Top End hospitals, in consultation with the developers, and it was endorsed for piloting by the NT Health Aboriginal Health Committee.
In addition to ‘Ask the Specialist Plus’, a community of practice of culturally safe clinicians known as champions of cultural safety, will be further supported by a chat platform and seminars provided by invited experts; as below.
Strengthening the tools and strategies that underpin culturally safe practice
Improve the demand for Aboriginal interpreters and Aboriginal health practitioners
A goal of the Community Study partnership is expansion of, and effective incorporation of, the First Nations workforce in health. Demand for this is driven in part by the knowledge and attitudes of mainstream healthcare providers as they gain better understanding of the limitations of biomedical approaches to address First Nations patient needs, and of the value of engaging interpreters and Aboriginal Health Practitioners (Aim 2a). Note, we include Aboriginal Health Practitioners, but traditionally their role has chiefly been in primary care rather than tertiary services; while the project will advocate for growth in the tertiary space, the main focus will be on interpreters. Demand will be promoted by ‘Ask the Specialist Plus’ training in communication and cultural safety, and by champions of cultural safety working directly in patient care roles.
‘Champions’ will participate in a chat group hosted on WhatsApp Inc. (WhatsApp Messenger, Meta Platforms) to discuss matters relating to cultural safety, and will be invited to seminars approximately once every 2 months. These activities will create a community of practice which values anti-racism approaches in clinical medicine and broader healthcare. Members will comprise multidisciplinary healthcare providers (nurses, doctors, allied health; Indigenous and non-Indigenous). We will specifically invite those working at participating hospitals, but primary care practitioners who express interest will also be welcome (noting that healthcare providers in the Northern Territory often transition between services, and the activities have broad relevance). A ‘snowball’ (word of mouth) strategy will be used to expand membership of the group. Members can silence or exit the group as they wish. APR, VK and the research assistant(s) will moderate the group and provide occasional conversational prompts and responses. The chat platform will provide a forum to share observations and questions about working in the Northern Territory intercultural healthcare context, and share ideas, articles and other resources. Common issues such as how to handle or call out racism observed at work, and practical strategies such as incorporating information on the patient’s nation and language in handover, and promoting Aboriginal interpreter use in day-to-day practice, will be addressed.
The project team will also use all available opportunities to advocate for cultural safety and use of Aboriginal interpreters at teaching sessions, Grand Rounds, clinical handovers, through presentations to hospital committees, and preparation and dissemination of policy and practice briefs arising from research findings.
Improve the supply of Aboriginal interpreters and Aboriginal health practitioners willing and able to work in the hospital environment
Fulfilling this aim, 2b, requires the creation of a culturally safe workplace, and support for career pathways in health interpreting and healthcare for First Nations peoples. Interpreters can be employed prior to gaining qualifications, using an on-the-job learning model to ultimately gain certification through the National Accreditation Authority for Translators and Interpreters (NAATI). A major new commitment from Northern Territory Health for this partnership project is to directly employ interpreters (‘Communicating for Safety officers’) representing some of the commonly spoken languages, to complement the service provided by the external NT Aboriginal Interpreter Service. This will roll out at Royal Darwin Hospital in the first instance. On-site availability will improve visibility and availability of the service. Creation of a cohesive, supported team will help mitigate the intimidating nature of the work environment [5, 9].
To support staff retention, the project will encourage structural assistance (office space), formal training pathways (progression through to full NAATI certification), a sense of belonging (being oriented, attached to teams), supervision (task lists, goals, feedback), mentoring (motivational coaching and career advice), debriefing and psychological support (referral to counselling services if workplace stressors are impacting mental wellbeing). These activities will be led by health service research partners, specifically, the Aboriginal Support Units at participating Northern Territory Health hospitals. Additionally, training in health concepts and hospital processes for interpreters to improve confidence in health interpreting will be coordinated initially by the study team with the plan to hand this role over to hospital education units. Interpreter training needs are based on problems and health-related questions the interpreters have identified. Training in health concepts will be supported by the development of a Plain English Dictionary of health words. Anonymised feedback from interpreters obtained from interviews, observations and debriefing processes will be included in CQI cycles to ensure senior managerial staff and others are aware of and responding to First Nations workforce needs. As in Aim 1, cultural safety is pivotal – we hypothesise that a more culturally safe workforce achieved through scale up of training will improve interpreter experience.
Integrate supply and demand through efficiency and effectiveness strategies
Simplification of processes for booking an interpreter will be introduced. Lanyards including telephone and email contacts for the hospital interpreters and the Aboriginal Interpreter Service will be distributed. The Northern Territory Aboriginal Interpreter Service booking forms will be made more readily available on each ward and ward clerks will be upskilled in the bookings processes. Working with Interpreter Training will be built into ‘Ask the Specialist Plus’ training sessions for healthcare providers. It covers who needs an interpreter, ‘teach back’ [41] to ensure comprehension, non-judgemental framing of the need for an interpreter, and briefing/debriefing of interpreters. Other strategies will be explored to optimise workflow to facilitate efficiency and availability across hospital departments, such as interpreters being based on wards and integrated into ward rounds with highest numbers of Aboriginal language speakers (typically Renal and Paediatrics) in the mornings, and outpatient clinics in the afternoons.
This study will also fill the gap in health training currently experienced by Aboriginal interpreters. Education on health concepts, hospital processes and health language will be developed. Educational sessions between clinical health care workers and interpreters will explore common medical conditions, their diagnosis and treatment, as well as patient experiences in hospital. A Plain English dictionary of health terms will be supported and distributed. The value of a career in health interpreting to help achieve improved outcomes for First Nations peoples will be promoted through mentoring and biennial First Nations Languages and Health Communication Symposia, coordinated by the Communicate Study team [42].
Evaluation strategy
As indicated, we will use the RE-AIM model for overarching program evaluation [24, 26] (Table 5). It meshes well with the TIDieR checklist (Supplementary Table), the subheadings of which also broadly address reach, effectiveness, adoption and implementation. The mixed-methods RE-AIM evaluation will incorporate analysis of interviews and observations, time series analysis of hospital admissions, interpreter bookings data and costs, and application of the Kirkpatrick model of learning to evaluate training [43, 44]. The Kirkpatrick model describes 4 domains for assessing quality and outcome of education: Level 1: reaction (satisfaction, engagement); Level 2: learning (knowledge and skills obtained); Level 3: behaviour (application of knowledge / skills); and Level 4: results (benefit to patients).
Table 5
Application of the RE-AIM framework to this project
RE-AIM dimension and operational definition
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Plan
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Indicators
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How will I and the intervention reach the targeted population?
Reach is the absolute number or proportion of individuals who are willing to participate in a given initiative
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• The project team has First Nations leadership with cultural advice and community engagement fostered by First Nations members of the investigator team and project staff
• Relevant stakeholders at participating service organisations are all involved as project partners
• Members of the project team work within the services directly with the target populations
• Healthcare providers are directly reached through cultural safety training sessions, being part of a social media chat group, and attending evening seminars on cultural safety, providing direct reach
• We will build on the already established connections and relationships we have
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• Number of health providers who participate in training, seminars, observations and interviews and who become cultural safety champions.
• Number of people who participate in continuous quality improvement meetings
• Number of interpreters employed, and staying in employment, and who participate in training and interviews.
• Number of patients who participate in sharing stories about their experiences of healthcare
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How do I know my intervention is effective?
Effectiveness is the impact of an intervention on outcomes, including potential negative effects, quality of life, and economic outcomes
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• Qualitative and quantitative outcomes will capture effectiveness of study activities in improving
o cultural safety, as determined by patients
o patient hospitalisation outcomes
o healthcare provider capabilities and attitude and behaviour change
o workplace experience for interpreters and healthcare providers
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• Number of patients with
- documentation of language
- documentation of interpreter need
• Interpreter bookings
- made
- completed
• % Aboriginal patients in need getting access to an interpreter
• Hospitalisation outcome
- Self-discharge
- Unplanned re-admission
- Hospital length of stay
- Cost
• Post-training survey data (Kirkpatrick model)
• Improved patient experience of care
• Improved interpreter and healthcare provider workplace experience
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How do I develop organizational support to deliver my intervention?
Adoption is the absolute number, proportion and representativeness of settings and intervention agents who are willing to initiate a program
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• All partner organisations have given written commitment to improving cultural safety and promoting interpreter access
• Study team members will present study findings and prepare policy and practice briefs to be tabled at organisational meetings, and responded to (such as the NTG Aboriginal Health Committee)
• Hospitals recognise that the project helps them reach required national standards (National Safety and Quality Health Service Standards) to achieve accreditation
• The National Accreditation Authority for Translators and Interpreters has a goal of certifying more Aboriginal interpreters; this project will help achieve that aim
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• Engagement in investigator meetings
• Uptake of study newsletter (number of people who open the electronic newsletter)
• Invitations to the study team to present at partner organisation seminars, grand rounds, committee meetings
• Endorsement of study outputs and uptake of Policy and Practice briefs provided by the study
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How do I ensure the intervention is delivered properly?
Implementation refers to the intervention agents’ fidelity to the various elements of intervention’s protocol
|
• The project receives cultural guidance from inception through to implementation and analysis and dissemination from First Nations Elders and leaders, who provide expert cultural and language advice and guidance
• The project is run by an experienced team of study investigators, with a qualified project manager and research assistants
• The project team is supported by research institutional structures to ensure appropriate operations (business manager, ethics committee and financial manager)
• Activities, milestones and implementation issues will all be logged on an ongoing basis
• Quarterly investigator meetings and continuous quality improvement meetings will provide mechanisms for keeping study implementation on track and adherent to the proposed methods
• Weekly project team meetings will maintain momentum
|
• Activity log
• Project milestone reporting to the funding agency
• Annual reports to the ethics committee
• The way in which intervention components may be tailored or modified during implementation will be documented in the implementation log
|
How do I incorporate the intervention, so it is delivered over the long-term
Maintenance is the extent to which a program or policy becomes institutionalized or part of the routine organizational practices and policies.
|
• The use of continuous quality improvement will embed practice locally at each participating site, and sustainably.
• The implementation model will transition training activities from being run initially by the project team to being run by the participating services during the course of the study, especially as evidence of the value of the training mounts
|
• Transfer of facilitation of ‘Ask the Specialist Plus’ from the study team to the health services
• Transfer of health training coordination and delivery for interpreters from the study team to the health service / Aboriginal interpreter Service
• Evidence of actions and advocacy by Cultural Safety Champions initiated independently of the project
|
Quantitative data collection
Data sources will comprise the Admitted Patient Care datasets from participating hospitals, Aboriginal Interpreter Service records of interpreter bookings and completions, and bookings data from hospital-based Aboriginal interpreters.
Admitted Patient Care datasets
Hospital admissions data will be requested from the Northern Territory Health Analytics branch for the 2-year baseline period (July 1 2020 - June 30 2022; Fig. 1) and in quarterly instalments from the start of the activity period until the end of the study (July 1 2022 - June 30 2026). Inclusion criteria are all admissions of people identifying as Aboriginal or Aboriginal and Torres Strait Islander. There is no age restriction. We anticipate approximately 20,000 eligible admissions per year across the participating hospitals. The following variables will be requested: hospital record number, ward, admission date, discharge date, admission code urgency and type (to identify re-admissions within 30 days), discharge destination and type (to identify self-discharges), length of stay, ICD-10-AM codes (International Statistical Classification of Diseases and Related Health Problems, 10th revision, Australian Modification) to gauge complexity of admission and AR-DRGs (Australian Refined Diagnosis Related Groups) for costing data. Discharge type will be categorised as deceased, discharged home, transferred to another facility, or took own leave (including both ‘Left Against Medical Advice’ [signed themself out] and ‘Take Own Leave’ [left without notifying anyone]). Ward will be defined as the last ward people are transferred to other than the discharge lounge (aiming to capture the home ward, rather than interim wards such as Emergency, Intensive Care, or an outlying ward where a temporary bed is available). Data will be examined according to individual hospital and aggregated across all hospitals.
Aboriginal Interpreter Service (AIS) records will be sought for the same baseline and follow up periods for all bookings made for Aboriginal hospital clients including interpreter booking request date, language, ward, name (for linkage purposes), date booking completed or whether booking is able to be fulfilled / completed or not. AIS booking data will be examined to explore patterns of uptake related to wards, hospitals, language/community groups, gender and age. Hospital record number has not been recorded previously; we will work with the AIS to include this variable in their database and will develop an algorithm to link with hospital records based on name and hospitalisation date for the retrospective (baseline) period.
Separately, bookings for the interpreters employed directly through health services (‘Communicating for Safety officers’) will also be accessed, including client hospital record number, date, language and open text about the nature of the job (e.g. for informed consent for a procedure; end of life discussion; giving a diagnosis).
Quantitative data analysis
The linked dataset of hospital admissions and interpreter bookings will be analysed using interrupted time series analysis to examine change in gradient and intercept from an available 2-year baseline period to the 4-year intervention period in each outcome separately. Models will be fitted to estimate slopes during the two periods and the difference between slopes, as we have done previously using the similar datasets but not linked on patient identifier [6]. Analyses using the linked dataset will compare outcomes in First Nations patients who did or did not have access to an interpreter during a given hospitalisation, using logistic regression analysis or mixed effects models accounting for patient variables.
Economic evaluation will be conducted from the payer perspective and include the linked APC and Aboriginal Interpreter Service datasets and NT Health unit expenditure reports, as well as ICD-10-AM codes and AR-DRGs. ICD-10-AM codes will illustrate complexity of each admission, and DRGs will provide the re-imbursement cost for admission (under activity based funding [45]) and the median and inlier/outlier values for length of stay. These will be used to compute the consequences of self-discharge, for example, whether self-discharge occurred very early in a complex admission compared to the anticipated length of stay for that diagnosis, therefore likely to have major consequences and high chance of re-admission. Additional analysis will compare length of stay to the national average, before and during the study. Decreases in length of stay (not associated with early discharge) are likely to have a cost benefit impact on the health system. However, increased length of stay may ultimately have a cost benefit if associated with decreased re-admission rates, which we can measure, or improved health outcomes, which will be more difficult to capture.
Service and salary costs associated with interpreter use and staff time to undertake training and mentoring will be calculated using expenditure reports. Based on the time series modelling undertaken for the quantitative analyses, compiled costs will be input into the models to examine expenditure trends before and after intervention. Probabilistic sensitivity analysis will be used to characterise parameter uncertainty in relation to the level and slope of model outputs (expected hospitalisation rates and costs). Generalised linear modelling will be used to determine variables that have a potential influence on costs (such as hospital, ward, language, age, gender). Incremental cost differences between the projected expenditure trends before and post intervention at years two and four will be calculated. Incremental costs will demonstrate impact and sustainability of the model.
Qualitative data collection
Qualitative analyses will explore impacts of study activities on First Nations patients, as well as interpreters and healthcare providers, and their interactions with each other, during project implementation compared with baseline data. Data sources will include interviews, observational field notes and journals. Collection and analysis of qualitative data will be an opportunity for First Nations employees to develop their research skills. A core group of English and Aboriginal language speakers will undertake training to participate in or conduct interviews, translation and analysis.
As per Participatory Action Research approaches, individuals who have a vested interest in improving culturally safe communication in healthcare will be purposefully sampled. Patients, interpreters and healthcare providers who can provide “information rich cases” which exemplify dysfunction and expose systemic issues to be addressed and opportunities and strategies for change will be invited to participate [29, 46]. Logical generalizations relating to systemic issues can be made from a small amount of in-depth evidence. The intention in gathering such data which explores the insider perspectives of key informants is two-fold: to evaluate the impact of study activities, and to provide informative data back to the partner institutions on strategies for improving the quality of care [47].
Patients
Cultural safety will be assessed through in-depth interviews with patients in their preferred language. Patients and families will be invited to yarn with researchers about their hospital experience [48]. A yarning guide has been developed to facilitate a semi-structured discussion about what matters to patients regarding communication and cultural safety when seeking healthcare in the Northern Territory. These yarns will be conducted by a bilingual researcher, or by an English-speaking researcher with an interpreter as required and will be audio recorded with permission. These data will be the main means of capturing patient experience and will be used as the ‘gold standard’ against which results of any patient experience survey which might be developed (see below) can be compared. Inclusion criteria are: identifies as First Nations Australian, is receiving inpatient or outpatient care at one of the participating study hospitals and/or is a trusted family member of a patient, and can provide informed consent.
Patients may prefer a group discussion including their accompanying escort or other family members, rather than a one-on-one interview. Therefore relatives, next of kin or carers will also be eligible to participate if the patient wishes. Guardians of paediatric patients or of patients with dementia or disabilities will also be eligible to participate to ascertain their perception of the extent to which the experience for them and the patient was culturally safe. Written, informed consent will be obtained from each participant using a form written in English, with interpreter explanation as required. Patient participants will also be asked for consent to record their hospital record number for the purpose of cross-checking points arising from the interview against medical records should that be required. Issues of concern raised by patients will be escalated appropriately, if they agree, through the treating medical team or the patient advocate.
A purposive sampling approach will be used with maximum sample diversity (patients with diverse first languages including English; who need and did/did not have access to an interpreter; of different genders, age and care type). Potentially eligible participants will be identified through consultation with Interpreters, Aboriginal Liaison Officers and clinicians (including the Cultural Safety Champions) and community contacts. Potentially eligible participants will be approached by a researcher in their first language to discuss the purpose of the study and seek consent. The information and consent process and interviews will not be done by healthcare providers directly involved in a patient’s care.
Approximately 10 patient participants will be interviewed prior to commencement of ‘Ask the Specialist Plus’ training, and approximately 3 per year for the remaining 4 years, providing at least 20 in depth patient interviews. A subset of patient participants will be invited to participate in follow up interviews either within a single admission, or across admissions. This will include patients who have a prolonged stay, or who access healthcare repeatedly for chronic conditions (e.g. renal dialysis, chronic infection, chronic cardiac conditions). Our previous research identified that follow up over time with a single individual can allow a rich story to be fully explored, as well as providing the chance to review research findings with the participant and check that interpretation is correct [4]. Long-term patients provide greatest sensitivity to change within health systems.
Interpreters
Interpreters (± Aboriginal Health Practitioners) will be invited to participate in semi-structured interviews at baseline and during study activity implementation. Inclusion criteria will comprise Interpreters (± Aboriginal Health Practitioners) who are employed by or have recently worked at a participating hospital (e.g. within the last 3 months), who provide written, informed consent. We will seek to interview 5 interpreters at baseline and at one or two follow up time points, giving a total of at least 15 interviews. Interviews will explore how interpreters perceive their role, the healthcare providers who they work with, their career pathway, workplace support, and their perceptions of institutional cultural safety for First Nations health professionals and patients. Based on previous work [5] and ongoing conversations, interpreters play multiple roles in the hospital including as cultural brokers and providing ‘welfare checks’; interviews will provide insights into the breadth of their roles. The recruitment strategy will comprise direct invitation to the interpreters employed at any of the participating hospitals or by the Northern Territory Aboriginal Interpreter Service, and Aboriginal Health Practitioners employed at the hospitals.
Healthcare providers
Diverse clinicians (nursing, medical, allied health) from a range of cultural backgrounds and hospital departments will be sampled (approximately 10 per year; 50 in total) and interviewed by a member of the Communicate Study team. Healthcare providers will be eligible if they work or have worked within the last 3 months at one of the participating hospitals. Written, informed consent will be sought and interviews will be audio-recorded. Ward-based healthcare providers will be recruited through the networks of the investigator team and snowballing. The interview guide will focus on perceptions of hospital culture and their own culture in engaging with First Nations patients, barriers and enablers to intercultural communication, power, racism and engagement in reflective practice. Our previous research has found these in-depth interviews provide doctors with opportunities to critically reflect on medical and hospital culture without fear of retribution from their employer or judgement from colleagues [9]. Reflective interviews assist healthcare providers to develop their critical consciousness which is required to instigate change. Interviews will also seek to capture attitudinal and behavioural changes relating to participation in ‘Ask the Specialist Plus’ and feedback on the usefulness of the Cultural Safety checklist. In addition to interviews, healthcare providers will be encouraged to keep a journal to encourage further reflection and track their own progress. Suggestions will be sought from healthcare providers about how to address the systems issues which hinder successful professional collaborations with the First Nations health workforce.
Observational data
Hospital-based healthcare providers, who have consented to be interviewed in relation to the ‘Ask the Specialist Plus’ training evaluation, will be observed by researchers interacting with other staff, patients and families. Observations will occur approximately one month before training commences and within two months after training is completed. The decision to observe healthcare providers one to two months after the final training session allows researchers to observe if they were able to maintain the attitude and behaviour change speculated (as hypothesised by trainers, and as participants may indicate in their surveys). An observation guide will assist the researcher to focus on key features of the interaction relating to culturally safe communication. Researchers will describe in writing the physical environment, note who was present and if First Nations staff were part of the interaction. They will observe and document the healthcare providers’ verbal and non-verbal communication style which includes tone, volume, medical jargon, silence, active listening, taking action etc. Afterwards, researchers will reflect on what they observed prompted by their written observation records. Observational data helps to guide reflective interviews with healthcare providers, is analysed as data alongside interviews and assists researchers to better understand the systemic issues healthcare providers face.
Qualitative data analysis
Supporting the transformative goals of PAR, a critical theory lens which examines power relations embedded in social, political and cultural contexts will guide analysis [49]. Interviews conducted in English will be transcribed verbatim. Interviews conducted in a First Nations language will be interpreted into English by a native speaker/researcher using meaning-based interpreting [50]. Key words or concepts expressed in First Nations languages will be retained to ensure cultural meaning is not lost in translation. During analysis, First Nations researchers are cultural brokers drawing on their own knowledge to ensure stories are accurately represented and understood. Data from patients, interpreters and healthcare providers will be uploaded to NVIVO software (QSR International Pty Ltd, 2020) and inductive narrative analysis will be undertaken to identify key turning points in people’s stories (epiphanies), or triggers leading to change in behaviour or change in experience [51]. Data pertaining to training (interpreter health training and ‘Ask the Specialist Plus’) will then be deductively organised into the four categories identified in Kirkpatrick’s training evaluation framework: reaction, learning, individual behaviour change and organisational impact [43]. After the data have been analysed and reconstructed into stories as draft publications, participants will be contacted to review how their story has been told. This process, usually undertaken as a conversation with researchers and participants, ensures stories are verified and also gives participants a final opportunity to add important details.
In PAR projects, participants sometimes wish to use their real name, not a pseudonym. In the Communicate Study’s consent processes, participants are asked to choose whether and how they would like to be identified in the research. Pseudonyms in research can protect the identity of participants but they can also erase the connection between an individual, their culture and knowledge. In our previous research, some participants used their real names to ensure knowledge shared was attributable to them thereby maintaining sovereignty over ideas [9].
Illustrative qualitative findings will be presented alongside the quantitative data in CQI meetings to help motivate health system learning and change.
Activity and implementation logs
A log of project activities such as meetings with partner organisations, milestones in approvals processes (ethics, research governance, inter-institution agreements), presentations, data collection, training sessions run by the study team, and other key events, will be recorded in a backed-up diary. This will help inform milestone reporting to the funding agency, the study newsletter, annual ethics reporting as well as providing data for the evaluation (e.g. ‘Implementation’; see Table 5). The way in which intervention components may be tailored or modified during implementation will be documented in a study implementation log.
A regular electronic study newsletter will be distributed to broad recipients (investigators, stakeholders, other interested parties across the participating organisations or beyond) using a platform such as Mailchimp™ Application Programming Interface. Available metrics on measures such as proportion of recipients who open the email will be collected.
Survey data
Patient experience survey
We will work with relevant health service and research groups to determine a process to capture patient experience that is implementable at scale, captures what actually matters to First Nations people, and provides an accurate assessment of hospital experience. This will draw on the existing recommendations on capturing patient experience described in the Australian NSQHS Standards, on research into best ways to capture patient experience, particularly First Nations patients [52–55], and on our previously published findings which identified a mismatch between findings of ‘tick-box’ patient experience surveys and more in-depth conversations with a trusted data collector [5]. Communicate Study investigators will work with project partner organisations to support piloting, further development, roll-out and longitudinal evaluation of the patient experience tool. This will become a routine health service activity not requiring a consent process. No identifiers will be collected.
Staff surveys
Healthcare providers will be invited to participate in paper-based or online surveys after participating in ‘Ask the Specialist Plus’ [56] training. This will determine responses across the 4 elements of the Kirkpatrick model of learning [43, 44]. The inclusion criteria will be healthcare providers (doctors, nurses, allied health practitioners) who participate in ‘Ask the Specialist Plus’. Participants will be invited to complete a survey assessing responses across the 4 elements of the Kirkpatrick model of learning at the conclusion of each training session. Consent will not be sought since no identifying information will be collected. The ‘Ask the Specialist Plus’ pilot resulted in high survey completion rate and high satisfaction (unpublished data).