Evaluation of ‘Ask the Specialist’: a cultural education podcast to inspire improved healthcare for Aboriginal peoples in Northern Australia

ABSTRACT

In Australia’s Northern Territory (NT) most people who access health services are Aboriginal and most healthcare providers are non-Indigenous; many providers struggle to deliver culturally competent care. Cultural awareness training is offered however, dissatisfaction exists with the limited scope of training and the face-to-face or online delivery format. Therefore, we developed and evaluated Ask the Specialist: Larrakia, Tiwi and Yolŋu stories to inspire better healthcare, a cultural education podcast in which Aboriginal leaders of Larrakia, Tiwi and Yolŋu nations, known as the Specialists, answer doctors’ questions about working with Aboriginal patients. The Specialists offer ‘counterstories’ which encourage the development of critical consciousness thereby challenging racist narratives in healthcare. After listening to the podcast, doctors reported attitudinal and behavioural changes which led to stereotypes being overturned and more culturally competent care delivery. While the podcast was purposefully local, issues raised had applicability beyond the NT and outside of healthcare. Our approach was shaped by cultural safety, critical race theory and Freirean pedagogy. This pilot is embedded in a Participatory Action Research study which explores strategies to improve culturally safe communication at the main NT hospital Royal Darwin Hospital.

KEYWORDS:

• Healthcare
• communication
• cultural safety
• training
• podcast
• racism

Introduction

Aboriginal peoples, the original inhabitants of the unceded lands known as Australia, are the world’s oldest continuous civilisations (Burarrwanga et al., 2019). Over the last 200+ years colonisation has resulted in a disproportionate burden of disease and poorer health outcomes for Aboriginal peoples. In the Northern Territory (NT; ‘the Territory’), Aboriginal peoples comprise 30% of the population (Australian Bureau of Statistics, 2018) yet constitute at least 70% of hospitalisations (Northern Territory Government, 2021). Healthcare providers unfamiliar with the diversity and strength of Aboriginal cultures in the NT, struggle to deliver culturally competent care (Amery, 2017; Kelly, Dowling, McBride, Keech, & Brown, 2020; Kerrigan et al., 2021a, 2021b): there is a perception that Aboriginal peoples are ‘non-compliant’ and ‘they don't listen’ (Anderson et al., 2012; Kerrigan et al., 2021b). Racist stereotypes of ‘suspicious blacks, hostile blacks’ were held by colonisers before they arrived in Australia (Moreton-Robinson, 2011, p. 421) and continue today fostered by media reports which link Aboriginal peoples with harmful behaviours (Stoneham, Goodman, & Daube, 2014; Watego, Singh, & Macoun, 2021). This racist discourse seeps into mainstream health services, resulting in Aboriginal peoples feeling unsafe (Thurber et al., 2021; Watego et al., 2021).

For over 50 years, cultural awareness training has been proffered as a panacea to intercultural issues in healthcare, however, the training has been criticised for homogenising Aboriginal cultures (Downing, Kowal, & Paradies, 2011; Shepherd, 2019) and reinforcing negative stereotypes as it perpetuates ‘othering’ (Brascoupé & Waters, 2009; Byrne & Tanesini, 2015). As an alternative, there is momentum around the concept of cultural safety which was developed to counter racism in healthcare (Ramsden, 2002). Cultural safety requires healthcare providers to develop their critical consciousness in addition to having ‘a degree of knowledge and understanding of other cultures’ (Curtis et al., 2019, p. 14). When individuals are critically conscious they are aware of the social, economic and political systems that oppress people and have capacity to reflect on their ‘assumptions, biases and values’ (Kumagai & Lypson, 2009) and can act to change systems of oppression (Freire, 1970). The concept of critical consciousness links cultural safety with Freirean pedagogy and Critical Race Theory (CRT) (Delgado, Stefancic, & Harris, 2017; Freire, 1970). Both Freirean pedagogy and CRT attempt to develop critical consciousness by elevating the ‘experiential knowledge of people of color’ through storytelling (Smith-Maddox & Solórzano, 2002, p. 71). Previous Australian research has found when healthcare providers are exposed to stories shared by Aboriginal peoples critical thinking relating to Whiteness and privilege occurs (Grogan, Hollinsworth, & Carter, 2019; Sjorberg & McDermott, 2016; Wain et al., 2016). Australian governments have committed to addressing racism in healthcare through ensuring care is culturally safe (Australian Commission on Safety and Quality on Health Care, 2017; Australian Government, 2013; Northern Territory Government, 2021) however, there is a gap between policy and implementation and a paucity of evidence that cultural safety training can achieve its intended outcomes.

At the time of this study, there was no cultural safety training mandated for NT Health staff. Our research of cultural awareness training for NT health found only 30% of staff attend (Kerrigan, Lewis, Cass, Hefler, & Ralph, 2020). Training was perceived to be an institutional tick-box exercise and met with ‘eyerolls and groans’ (Kerrigan et al., 2021b). We evaluated over 600 cultural awareness training participant feedback forms, to assess if negative attitudes also existed amongst the small percentage of NT Health staff who attended training (Kerrigan et al., 2020). We found the one-day face to face training was considered a valuable starting point by staff who recognised their knowledge gaps. Staff want more training which focuses on intercultural communication which is clinically relevant. Importantly, participants requested training which encourages critical reflection to support the development of critical consciousness (Kerrigan et al., 2020). Additionally, our research found a highlight of cultural awareness training was the personal stories shared by Aboriginal educators which have the potential to decolonise the healthcare system by reasserting ‘Indigenous voice, perspective, and experience’ (Behrendt, 2019, p. 175). CRT scholars (Delgado et al., 2017) refer to such stories as ‘counterstories’, which challenge stereotypes and encourage a reallocation of power. Delgado (1989) argues counterstories are ‘the cure’ to ongoing racial inequities. Hence, we designed a new cultural education package which privileges Aboriginal peoples’ stories of healthcare and encourages critical thinking.

Ask the Specialist: Larrakia, Tiwi and Yolŋu stories to inspire better healthcare is a cultural education package which consists of a podcast and discussion groups. ‘The Specialists’ are Larrakia, Tiwi and Yolŋu leaders: Aunty Bilawara Lee, Pirrawayingi Puruntatameri, Rarrtjiwuy Melanie Herdman, and Stuart Yiwarr McGrath. Kriol and Burarra interpreter Bernadette Nethercott from the NT Aboriginal Interpreter Service also shared expertise. The aim of this paper is to explore the impact of the Ask the Specialist podcast (7 x <18-minute episodes) on Royal Darwin Hospital (RDH) doctors’ attitudes and behaviour. We will explore if the counterstories (Delgado et al., 2017) provided by the Specialists stimulated the development of the critical consciousness (Freire, 1970) required to challenge negative stereotypes and change practice.

Methods

Study design

This pilot study was part of a larger Participatory Action Research (PAR) project in which Aboriginal educators, interpreters and health professionals collaborated with hospital-based doctors and researchers to address barriers to culturally safe communication at RDH (Menzies School of Health Research, 2018). The theoretical framework was guided by Freire’s theories on education (1970), CRT (Delgado et al., 2017) and cultural safety (Ramsden, 2002). While Freirean pedagogy originated in Brazil, CRT originated in American legal studies and cultural safety was developed among nurses in New Zealand/Aotearoa, when combined the theories offer an alternative paradigm, as detailed above, to explore the creation of a culturally safe health workforce in the NT (Braun, 2017; Kumagai & Lypson, 2009; Ramsden, 2002). While cultural safety can only be determined by patients, the work to create a culturally safe workforce must be done by the health providers who are required to:

critique the ‘taken for granted’ power structures and be prepared to challenge their own culture, biases, privilege and power rather than attempt to become ‘competent’ in the cultures of others. (Curtis et al., 2019, p. 14)

To create the podcast, we applied the Freirean concept of ‘problem posing education’ and the CRT concept of counterstories. The concepts are embedded in the title, Ask the Specialist: Larrakia, Tiwi and Yolngu stories to inspire better healthcare. The title promises that problems will be posed, and answers provided by voices marginalised by the mainstream. Furthermore, the title dislodges Eurocentric meritocracy (Delgado et al., 2017) by valuing the experiential knowledge of Aboriginal peoples. To produce podcast content, hospital-based doctors were invited to articulate the problems they encounter when working with Aboriginal patients. Doctors’ questions ranged from the practical: ‘When should I get an interpreter?’ to issues at the heart of cultural safety and social justice: ‘I want to know what Aboriginal people feel like when we talk to them, what makes them think that we're racist?’. Anonymised questions from doctors were then presented to the Specialists who provided their perspective thereby exposing counterstories, so often ‘hidden or minimised in the dominant discourse’ (Bell, 2003, p. 8), which reveal the reality of the hospital experience for Aboriginal peoples in the NT’s Top End. A detailed manuscript explaining how the podcast was created is underway.

Researcher backgrounds

Aunty Bilawara Lee is an Elder of the Larrakia nation. She has more than 50 years’ experience in education, health and the community sector and is acknowledged internationally as a healer and teacher of the ancient wisdoms of Aboriginal spirituality. Pirrawayingi Puruntatameri is a Tiwi Elder, his name translates to ‘someone who represents his people’. He has 40 years experience working in health, education, justice and the community sector. He is bilingual: Tiwi and English. Stuart Yiwarr McGrath is a Gumatj man from the Yolŋu nation; he is an Aboriginal Health practitioner, a student of nursing and researcher. He is bilingual: Djambarrpuyŋu (Yolŋu Matha dialect) and English. Rarrtjiwuy Melanie Herdman is a Gälpu women from the Yolŋu nation. Her work spans the health, environmental, political and research sectors and is encompassed in the Yolŋu phrase Rrambaŋi djäma: (working together). Rarrtjiwuy is bilingual: Dhaŋu (Yolŋu Matha dialect) and English. Vicki Kerrigan is an Australian born English speaking White researcher of Anglo-Celtic heritage, communication researcher and former radio broadcaster. The term White is capitalised in line with Whiteness studies stemming from the scholarship of Du Bois (2003). Reflecting on her proclivity as a White settler to assume the colonising role of the ‘cultural overseer’ (hooks, 2014) in the research space, Kerrigan uses PAR to work alongside Aboriginal collaborators to facilitate the collective production of knowledge (Hall, 1985). Academic supervisors Anna Ralph, Alan Cass and Marita Hefler are White researchers who have extensive history working collaboratively with Aboriginal peoples and organisations on health issues.

Study setting

In Australia’s far north, the Top End Health Service provides over 100,000 episodes of inpatient care annually and employs over 4200 full time staff across four hospitals: RDH, Palmerston, Katherine and Gove Hospital, and 57 remote health clinics (Northern Territory Government, 2018). Aboriginal peoples make up 70% of hospitalisations and 89% of remote clinic presentations (Northern Territory Government, 2021). Most staff are non-Indigenous, not from the NT and staff turnover is high. Often healthcare providers on short term contracts do not undertake cultural education, instead privileging the biomedical approach to health without considering Aboriginal ways of knowing, being and doing (Martin & Mirraboopa, 2003).

Participant sampling

RDH-based doctors who had been identified through personal and professional networks including referrals, from co-author APR who was a doctor at RDH, were purposefully sampled (Patton, 1990). Doctors were invited to participate because the doctor–patient relationship is at the heart of communication in healthcare (Brown, Noble, Papageorgiou, & Kidd, 2015) and they are considered opinion leaders and agents of change (Gabel, 2012). Doctors came from diverse cultural backgrounds, levels of professional experience and were eligible to participate if they planned to remain in the region for 12 months or more. This ensured doctors had opportunities to implement new culturally safe ways of working at NT Health thereby encouraging individual and institutional change.

Data collection

Over seven weeks (29 January 2020 to 11 March 2020), one episode per week was shared with doctors via a link to a password protected podcast host site. After listening to each episode doctors provided weekly reflections, guided by a list of feedback prompts. Weekly reflections, also called journal entries were shared via email, voice memo or text message. Reflections generated data to analyse, provided ideas to explore in final feedback interviews and as per cultural safety practice (Wilson, 2014) encouraged a continuous cycle of participant reflection, action and change over 7 weeks as explored in this paper. Finally, feedback interviews were recorded with doctors after listening to all seven episodes. Interviews occurred outside of work hours to remove the risk of impacting patient care.

Data analysis

Critical theory (Bronner, 2002), which underpins CRT, Freirean pedagogy and cultural safety, shaped analysis. Initially, inductive narrative analysis was applied to doctors’ reflections and interview transcripts were transcribed verbatim. Narrative analysis (Clandinin, 2007), conducted in NVIVO12, explored the data for turning points in doctors’ attitudes and epiphanies related to power and privilege. Codes were then deductively grouped into four categories aligning with Kirkpatrick’s training evaluation framework (Kirkpatrick, 1996). Kirkpatrick’s framework provided a structure to methodically describe changes in attitude, behaviour and systems. VK led analysis with input from co-authors. Through reviewing manuscript iterations, direct feedback from the Specialists, who are co-authors, was incorporated into the discussion. This approach recognises ‘Indigenous ways of thinking about the world are authentic sources of human knowledge’ (Turner, 2021, p. 184).

Ethical considerations

Regarding language and naming conventions, we use the nation collaborators belong to: Larrakia, Tiwi, Yolŋu and so on. The term ‘Aboriginal’ is used to refer collectively to the original occupants of mainland Australia. We recognise the term Aboriginal is a constructed category which exists in relation to European colonisation and, as Moreton-Robinson states, it does not capture ‘our respective ontological, epistemological, axiological and cultural subjectivities’ (2011, p. 413). Approval to conduct the study was provided by the NT Department of Health and Menzies School of Health Research Ethics Committee. Participation was voluntary and doctors could withdraw at any stage understanding that anonymised data would be retained. Doctors were given pseudonyms to ensure anonymity which are used in this paper. If doctors had concerns relating to the project, they were encouraged to speak to their workplace supervisor or the research team.

Findings

Participating doctors, interns to senior clinicians with more than 40 years experience in the region, worked across all four Top End hospitals: RDH, Palmerston, Katherine and Gove. Doctors had diverse cultural backgrounds: 9 White Australian, 2 Aboriginal, 1 Indian-Malaysian, 1 Irish, 1 American, 1 Zimbabwean and 1 English. Of the 16 doctors who posed questions to Specialists, 14 provided feedback about the podcast. One doctor didn’t listen to any episodes but participated in a follow up interview. Two doctors were uncontactable for feedback interviews.

Findings demonstrate doctors developing critical consciousness and how changes in attitude resulted in action. At times doctors struggled with their reflections as they recognised personal biases and system failures. Kirkpatrick’s four domains to evaluate training: reaction, learning, individual behaviour change and organisational impact are used to systemically present findings.

Reaction to training

Episodes were listened to by participants quietly at home, commuting to work, on aeroplanes, completing household chores, exercising, at work during a break and for Bridget listened ‘in bed at 4.30am unable to sleep’. The flexible format did not interfere with clinical or administrative responsibilities. Most did not listen at work; Susan explained completing the current online cultural training at work did not allow for reflection. Most doctors listened to episodes more than once: a senior clinician who had worked in the Top End for 4 years, Ian, said he ‘picked up different things each time’. At the end of each episode, there was a call to action asking doctors to reflect and consider how they can change to improve the delivery of culturally safe care:

That always really got me. A little bit of a dagger. It was great and I think it was really important for people to listen to this and to be self-critical and say … ‘If I proclaim to care about Indigenous health, that’s one of the reasons that I’m here, then why am I not putting my money where my mouth is and actually engaging like I should?’. (Simon)

Doctors appreciated that one episode was delivered per week over 7 weeks. A senior clinician in the Top End for 9 years, Bridget said because critical reflection is not encouraged in the acute care setting, she valued the staged roll out which ‘kind of forced me not to just listen to it but to really consider it and apply it to my practice’.

Doctors said the podcast contributed to professional development. A senior registrar who had worked in the Top End for 10 years, Melinda, said the podcast was ‘more useful than a didactic lecture or having an online learning module’. After listening to all episodes, Penny wrote in her journal that she noticed each episode built on concepts previously discussed: ‘So it’s a good teaching tool that way that it’s structured'. Doctors said the content covered cultural competencies and also inspired cultural safety practice. Aaron said: ‘this is the training that is required’.

Clinical care gold. This project will change the healthcare professional-patient communication landscape. Should provide the best outcomes for all our patients!! (Aaron, journal)

Doctors also valued the clinical vignettes shared by the Specialists which mirrored their experiences and provided examples of how to change behaviour. Penny journaled: ‘You have very successfully understood doctor culture and how our brains work’. She elaborated, in an interview, the podcast encouraged her to take responsibility for making change:

I think, the whole point of the podcast, is that it’s always, always about the listener. It’s about what you can do. How you can improve on these shitty situations which have happened to us … it’s really beautiful how you’ve placed this high-powered doctor in a listener’s seat, but still given them responsibility that it’s their job to do stuff differently, I think that’s magical. (Penny)

Doctors appreciated the Specialists made themselves vulnerable by sharing personal experiences. They recognised they can learn from patients if, as Ian said: ‘we just listen to them and show genuine interest’. Most doctors valued listening to the Specialists who held respected positions of authority in the community, although one doctor Ben questioned ‘how much these four voices are a good sample’ of Aboriginal perspectives. In contrast, Simon said:

It’s a specialist podcast for the same reason that I wouldn’t get a plumber to give a presentation about auto immune hepatitis. These are Specialists who are experienced with healthcare, who are cultural leaders, who have thought deeply about these issues and they’re the people you want to hear from. (Simon)

Doctors enjoyed hearing a variety of opinions which were at times contradictory. After listening to episodes 1–4 Toby journaled: ‘it’s clear that Aboriginal people are not a single entity as sometimes it is portrayed in the media, by hospital staff and in cultural education sessions.’ Whilst the diversity of Aboriginal cultures was evident, Ben and Ian were concerned doctors were presented as a homogenous group.

When they say, ‘Oh all the doctors always do this’, and you're a bit like, ‘Well not all of us all do that’. But yeah, I guess that's just being a bit defensive really isn't it. (Ian)

Melinda explained doctors take criticism ‘as a personal attack’ because they are expected to be ‘perfect’. One doctor, Paula, was reassured by what the Specialists said:

What was reassuring to me was that when doctors do – or other health professionals do – go to the effort to show respect and to engage with people, that that is noted and appreciated and that was a really nice thing to hear. (Paula)

After listening, some felt ashamed. A junior registrar in the Top End for 5 years, Simon, said: ‘I felt a bit of shame about perhaps not using interpreters and not engaging with patients in a way that I feel like I should.’ However, he and others, recognised this was a growth opportunity. Simon said talking about racism in healthcare ‘is a really emotional thing, it’s not purely cerebral’ and hearing directly from patients was different to other cultural education:

The anger is real … It’s not some conceptive image of Aboriginal people that are put on PowerPoints and everything, sort of rosy and peachy, it’s the messy reality. It gets ugly. We need to acknowledge that. (Simon)

One doctor, Susan was disappointed by how the podcast addressed racism:

I felt like it sort of skipped around the edges a little bit, sort of nibble, nibble … We tiptoe around racism, and I think even the Specialists kind of did. They gave some stories and some anecdotes, and it was more so thinking that people can’t read and write or whatever … it was a little bit around hospital procedures and incidents, but I think it failed to talk about maybe more the social determinants of health … I probably would have loved a bit more meat in those sort of hard-hitting type topics … because I identify as an Aboriginal woman, so I’m more in tune with some of this stuff than some other people. (Susan)

Toby also wanted the podcast to delve further into the ongoing impact of colonisation on health outcomes for Aboriginal peoples: ‘Can you talk more about the history of doctors in relation to the history of colonisation and oppression? It’d be uncomfortable but important listening.’

Penny described the podcast as ‘authentic to the Territory’. Simultaneously, doctors recognised the Specialists’ experiences, as Aboriginal peoples interacting with White health services, was repeated globally. Aaron said the stories were relevant to all patient-provider interactions: ‘I think this will actually go across cultures because what they were discussing is an absence of respect in care.’

All doctors, minus one, stated the podcast should be available to all staff. Melinda said allied health, nursing staff, cleaners and ward clerks ‘all create the culture of the hospital’. However, there was conflict over making the training mandatory. Some viewed mandatory training as an institutional tick-box exercise and were concerned if the podcast was institutionally branded staff would reject it because Drew explained ‘there's a history of things being inadequate’. For others, the podcast should be mandated for all including senior clinicians who role model behaviour:

When I see senior doctors who have worked in the NT a long time, I have realised I have an expectation they will be good at communication and will have special knowledge of cultural differences. But they don’t! They use medical jargon and don’t check patients’ understanding. They explain things in English and keep the interactions brief, telling the patient what’s going to happen and then leaving. I hope to see these podcasts become widely available and to be embedded in a broader culture of changing the way we do things – one day. I hope that senior staff who run our hospital see their shortcomings as much as junior staff like me see our own. (Joanne, journal)

Drew was concerned senior staff would resist the podcast:

You'll have a few people who have been around for a long while whose kneejerk reaction is, ‘I don't need this. I've been talking to Aboriginal people up here for 15, 20 years’. (Drew)

One doctor did not listen to any episodes. Anthony, a senior clinician who had worked in the Top End for over 20 years, said communication and cultural safety was not an institutional priority therefore it was not an individual priority. He explained that in the acute care setting the White biomedical approach to healthcare takes precedence over ‘the soft power skills, the ideas around communication, around engagement with patients, around culturally safe practice, these broad concepts are always deprioritised by us’.

Participant learning

We identified five major areas of learning which indicated participants were becoming critically conscious: the importance of communicating in a culturally safe manner, creating partnerships with patients, awareness of spiritual practices, countering stereotypes and addressing racism.

Culturally safe verbal and non-verbal communication

Doctors recognised a common theme was the importance of communication. After listening to episodes 1 and 2 Bridget journaled that improving communication is ‘relatively simple’ and it ‘has the potential for large benefits to both patients and my own career satisfaction’. Concrete examples of how to communicate respectfully, including asking older patients if they would like to be referred to as Uncle or Aunty were considered useful because doctors admitted they sometimes did not know what to say. Penny said that medical school taught her to communicate in a manner which is in direct contrast to the style recommended by the Specialists:

We’re meant to be in control of the conversation, and that is taught power. We’re taught how to get on top of people and to control what information they’re coming out with. When to stop them, when to start them, all of that, which I think you need to unlearn. (Penny)

Regarding non-verbal communication, in episode 4, Aunty Bilawara Lee recommended health providers wear Indigenous prints or local woven earrings to show respect because uniforms can trigger anxiety due to a history of institutional ill treatment. Toby journaled: ‘I wear Aboriginal prints a lot. “If you’re a racist or a bigot you will not wear an Aboriginal print” from Aunty Bilawara blew me away. I never thought of it in that way.’

Creating patient partnerships

Doctors learnt about the value of creating a partnership with patients. Simon said healthcare providers ‘lose sight of patient-centred care’ in overstretched and underfunded hospitals. Aaron realised many Aboriginal patients feel ‘degraded’ even though he believes his patients receive the best clinical care available. Penny said the Specialists stories reminded her that she was delivering care to ‘humans’ with complex histories:

We get taught that patients are often ‘things’. I think that’s what medicine teaches us … I feel like by doing that, it makes it easier to get on top because you can do ‘things to things’ … sometimes our job turns us into these robots. (Penny)

Awareness of spiritual beliefs

Doctors became aware of spiritual beliefs which may be subjugated to the delivery of biomedical healthcare. Episode 7 discussed the spiritual significance of blood to some Aboriginal peoples. Afterwards, Susan questioned whether taking blood was necessary to determine the treatment plan:

Talking about spirituality and blood, that wasn’t something that I was really aware of … And we just routinely take so much blood … in medicine, we tend to probably take more bloods than we probably need as well. So, I think it’s just maybe that awareness about: ‘is this going to change what we do in the next day? Do we need this blood test today? How urgent is this?’ (Susan)

Countering stereotypes

A commonly held stereotype that Aboriginal peoples self-discharge from hospital because they are ‘non-compliant’ was countered. After listening to episodes 1–4 Bridget journaled that she now appreciated ‘the strong cultural/family responsibilities and how this impacts on patients “compliance” with healthcare'. For Aaron the podcast overturned the stereotype he believed a lot of healthcare providers hold: ‘Aboriginal people coming from these communities, are not very well educated.’ Aaron said the stereotype exists because Aboriginal patients don’t complain when healthcare is inadequate, so providers assume health literacy is low. However, he learnt this was incorrect and that many don’t feel comfortable questioning the authority of doctors even when care was inadequate. Doctors realised that instead of questioning authority some exercise their limited power by self-discharging.

Addressing racism

Doctors learnt that institutional decisions created a culturally unsafe hospital. Episode 6 revealed there was no space for smoking ceremonies at RDH or Palmerston hospital. A smoking ceremony is an ancient ritual for Aboriginal peoples; among its functions is to promote healing. When the NT government opened Palmerston hospital in 2018, plans to create a space to conduct ceremonies were abandoned. Susan described the decision as institutional racism:

I’m so angry that there was meant to be a designated space at Palmerston (hospital) and that just got gobbled up in the bureaucracy. It’s absolutely, like we’re catering for other people and their needs in terms of having … the (Christian) prayer rooms and the Muslim prayer rooms … We’re trying to encourage people to come to hospital if they’re sick, use hospital services, engage in healthcare, and then we’re kind of half-arsed doing it. (Susan)

However not all doctors linked institutional decisions to their personal practice. Ben struggled to see the benefits of learning about systemic issues because he was unsure how the information was going to help him ‘change my practice tomorrow’.

The podcast also prompted doctors to recognise the everyday nature of racism. After episodes 1-6, Paula journaled: ‘Racism at RDH is often insidious.’ Simon described the hospital as ‘exhausting’. He added: There are so many little micro-aggressions that you see on a day-to-day basis and…it's facilitated by this environment that treats Aboriginal patients as second-class citizens. Doctors realised they don’t know how to report racist incidents. A junior registrar in the Top End for over a year, Susan said: ‘I don’t know if there are any formal avenues to actually report things like that.’

On-the-job behaviour change

Critical reflection, prompted by listening to the Specialists' stories, led to behaviour change to equalise the power imbalance between patient and provider in four major areas: investing time to build patient rapport, changing communication, working with interpreters differently and improving consent processes.

Investing time to build patient rapport

Doctors worked on building rapport to foster patient trust. A Top End doctor for 5 years, Drew said he was unaware Aboriginal people were looking for that connection and is now role modelling new behaviour: ‘We're not going to just charge into this ward round, we're going to slow down and we're going to take time and that's where we put value in the consult.’ Toby said he started to focus on ‘the stuff that brought us together rather than the things that pulled us apart’. He built ‘solidarity’ with a Tiwi Elder who was a patient through their mutual love of boy bands: ‘the biggest thing that brought us together was Boyzone, Westlife, Daniel O’Donnell (laughs). I’ve never seen a man love Boyzone that much'.

Changing communication with patients

After episodes 1–3, many asked Aboriginal language-speaking patients to teach them a few words. Bridget recognised this contributed to a ‘shift in power’. Aaron learnt how to greet his patients in 6 languages which helped establish ‘culturally therapeutic rapport’. During ward rounds a senior clinician Ben, who had worked in the Top End for 3 years, asked a Tiwi patient to teach him and his team of 7 doctors a few words:

And she totally brightened up … she stayed in our ward for something like two weeks because she ended up having quite a complicated course … So every time I would see her, I would say ‘Good morning’ in Tiwi or ‘Good evening’ in Tiwi … She taught me how to say ‘Goodbye’. And then the last day, when I went to say goodbye and I told her it was a real pleasure taking care of her and she said, in Tiwi, ‘Goodbye friend’ to me … And then she asked me another thing which was both gut wrenching and embarrassing … I said: ‘I’ll use what I’ve learned for other Tiwi speaking patients’. And she goes: ‘Oh, you’ve never taken care of Tiwi patients before?’ And it was just like, such an indictment … But I said: ‘No, I have taken care of a lot of Tiwi patients, and I have just never taken the time to do what I’ve done with you, and that was a mistake’. (Ben)

In episode 3, doctors were asked to consider rephrasing the question they ask patients at the end of every consult: do you have any questions? Asking questions for some Aboriginal patients may be considered impolite. Joanne reported better engagement after she started asking: ‘Do you have any worries?’. Susan was working with a senior clinician who was also involved in the pilot and noticed the clinician had rephrased the standard final question:

I’ve noticed that she actually will say to patients: ‘What questions have you got?’, rather than ‘Do you have any questions?’ So, it’s sort of opening up that space a little bit more … and it was something that stuck with me, because I’m like ‘Oh shit, how do I actually ask that question?’. So, I’ve tried to be a little bit crafty about how I go about that with my patients now. (Susan)

Working differently with interpreters

Doctors changed how they collaborated with Aboriginal interpreters. After episode 3, doctors told patients they, the healthcare provider, need the interpreter. Drew recognised the issue was his lack of language skills: ‘I have the problem because I don't speak Tiwi.’ Although Penny was concerned about respecting patient autonomy and not perpetuating colonial dominance by insisting on an interpreter. Doctors also started to brief interpreters before meeting the patient. Paula, a Darwin-based doctor for 15 years, said: ‘I hadn’t ever realised I should be doing that.’

Improving consent processes

Gaining informed consent from Aboriginal patients was of major concern to all doctors. In episode 5, Tiwi Elder Pirrawayingi Puruntatameri shared his experience as an RDH patient which entailed being handed a consent form with all boxes pre-ticked. Toby, a junior doctor in the Top End for 2 years, journaled: ‘Boxes ticked is an every time thing, god even I’ve been guilty of it in the past.’ After listening to episode 5, Toby saw the same thing repeated with another Tiwi Elder who required an operation:

I just remember seeing … a surgeon … who had completed a consent form and had ticked all the boxes already and it was just missing the signature in the notes and I just, I was very angry and it was very hard to sort of … articulate how angry I was to the other members of the team who saw me just rip the consent form up and throw it in the bin. (Toby)

About a year before listening to the podcast, Bridget’s team performed a major surgical procedure on a patient who was in custody. The consent for surgery was conducted in English even though the patient’s English proficiency was described as ‘poor’. Between the time of admission and surgery, the patient interacted with approximately 10 different doctors, nurses, Aboriginal Liaison Officers and other members of the multi-disciplinary team, yet no one asked the patient what language they spoke at home or suggested an interpreter. After the patient was discharged, the prison doctor lodged a complaint with the hospital: the patient had not understood nor wanted the surgery which was performed on them. A year after the incident, Bridget was unsure how the institution addressed the complaint. However, individually Bridget continued to consider her power as a doctor, how the patient was disempowered by both the hospital and the prison system and how gratuitous concurrence was possibly at play:

And throughout the podcasts, and the Specialists talking about their culture and the nodding and agreeing to things because they don’t want to conflict with what the White doctor’s saying and this and that, so they just agree that they understand. (Bridget)

Wanting to ensure she did not repeat the situation described, Bridget sought to change systems. She journaled that she had started work within her department ‘to improve our consent processes for Aboriginal patients and use of interpreter services’.

Value gained by the organisation

As the critical consciousness of individuals grew, they were able to identify the potential impact on the organisation. Doctors realised the hospital benefits from staff being culturally competent because it reduces self-discharge rates. Bridget said she better understands why patients may self-discharge and said she could have ‘avoided patients taking their own leave, if we had the dialogue about why they needed to leave’. Ben believed while the Tiwi patient interaction described above didn’t change clinical outcomes it may have contributed to the patient feeling culturally safe:

Those types of interactions, sort of build upon themselves so the next time she needs hospitalisation, the feeling of not wanting to come in may be a little bit less, hopefully, for her. And, you know, that sometimes can translate into people presenting earlier and not being so far along in their disease process, that it’s hard to take care of them. (Ben)

Delivering cultural education via a podcast meant doctors who had previously not attended cultural awareness training completed the task. Simon said the podcast provided ‘a real opportunity for self-development’ which does not currently exist. Doctors overwhelmingly stated cultural education should not be delivered during induction because Susan explained the content ‘gets lost’. New staff are overwhelmed by administrative tasks, keen to start their clinical placement, and have not yet experienced the strength and diversity of Aboriginal cultures and how that intersects with mainstream healthcare. Susan supported the podcast because she believed the Top End should be a leader in cultural education: ‘I think things need to be a bit more forward-thinking up here.’ Melinda suggested building on the current series:

I’d love to have another podcast perhaps about the similarities … emphasising in fact that, yes we’ve got some differences but in fact above and beyond, our similarities are also there and they need to be harnessed as a way of kind of working together. (Melinda)

Doctors requested a sustained education package delivered in protected time which included facilitated discussions after listening to each episode. Ian journaled he wanted to spend hours with the Specialists: ‘Each explanation they give leads me to another question!’ Before the podcast, doctors felt alone with their concerns regarding culturally unsafe care hence appreciated hearing their colleagues had similar questions. Ian said: ‘I like that it tackled some things that we never get to ask.’ Ben predicted that if health providers could discuss issues together with the Specialists, they could create a groundswell for institutional change:

It’s such a rare thing that we get to have these types of interactions, you know, where you kind of ask questions that you may be embarrassed to ask. And to do so in a group and in public, and be able to hear other people ask questions and sort of build upon each other. (Ben)

Discussion

Ask the Specialist: Larrakia, Tiwi and Yolŋu stories to inspire better healthcare podcast facilitated critical consciousness which led to attitudinal and behavioural change amongst hospital-based doctors in the Top End. Doctors learnt about the benefits of culturally safe communication and patient-centred care, the importance of spiritual practice and how institutional decisions can diminish cultural identity. Doctors changed behaviour in relation to building rapport with patients, asking patients questions, working with Aboriginal interpreters, and gaining informed consent. Doctors also reflected on long-held stereotypes and the everyday nature of racism. However, two doctors said the podcast did not adequately address racism or the impact of colonisation on health outcomes. Finally, the podcast format was preferred over face-to-face or online cultural awareness training as it allowed time-poor health professionals to engage with information when convenient (Berk, Trivedi, Watto, Williams, & Centor, 2020).

Podcast collaborators appreciated the critical feedback which will be considered for future projects. Aunty Bilawara Lee likened the podcast to a bidjpidji: ‘dragonfly’ in Larrakia. Like dragonflies symbolise enlightenment, the podcast shed light on a variety of clinically relevant issues pertaining to the delivery of culturally safe care. Whilst the podcast was uncomfortable listening for some, ‘courageous dialogue’ (Freire, 1970, p. 128) is required to create change. Our findings align with previous Australian research which found ‘good cultural safety education generates disquiet, but makes the uncomfortable comfortable enough’ (McDermott, 2012).

The Ask the Specialist podcast provided healthcare providers with an opportunity to listen to Aboriginal peoples talk authentically, emotionally and honestly about their healthcare experiences. As Pirrawayingi Puruntatameri explained, listening to the podcast may have been the first-time doctors had heard directly from Aboriginal peoples on these issues. The stories humanise patients which encourages the provider to move beyond prioritising the ‘voice of medicine’ to consider the ‘voice of the lifeworld’ which is commonly ignored in hospitals (Mishler, 1984). We agree with Wain et al. (2016) that, ‘stories enable learners to experience a new reality and encourage reflection on their own assumptions and values as well as on issues of social justice’.

The aural nature of podcasts is ideal to explore personal experiences, which are ‘intimately whispered into our ears’ creating a bond between storytellers and the listener (Lindgren, 2016). Intimacy generated through the podcast created an opportunity for doctors to have indirect positive contact experiences (Allport, 1954) with Aboriginal patients who may otherwise be perceived as perpetrators, social deviants or victims in the segregated society (Kerrigan et al., 2021b). Indirect contact, such as listening to a podcast, whilst not as potent as direct contact is often a practical alternative in segregated contexts (Brown & Paterson, 2016). Increasing intergroup contact is commonly used in anti-racism training and is considered ‘the most important approach for reducing prejudice’ (Elias, Mansouri, & Paradies, 2021, p. 324). Indirect contact has previously been found to change attitudes and behaviour and can lay the foundation for future successful direct contact (Brown & Paterson, 2016).

Freire’s theories on transformative education inspired the podcast question and answer format. Freire (1970) asserted ‘problem-posing’ education, which encourages critical thinking, has the capacity to liberate oppressed peoples from the societal status quo which maintain inequities. Problem-posing education ‘strives for emergence of consciousness and critical intervention in reality’ (Freire, 1970, p. 81). We believe the oppressor, as referred to by Freire, can also benefit from problem-posing education. Placing the onus for change onto the oppressor, in this case health providers, aligns with cultural safety praxis: those who hold power, and the potential to perpetuate racism, also hold power to change the systems that subjugate (Ramsden, 2002).

This study focused on supporting health professionals to change; this is ‘the key feature’ of cultural safety (Ramsden, 2002, p. 171). However as cultural safety can only be determined by patients there remains a need to assess if training improves patient experience and outcomes (Lock, Burmeister, McMillan, & Whiteford, 2020). Based on pilot findings reported here, our team have been funded by the National Health and Medical Research Council to explore patient experiences across four NT hospitals over 5 years. Our project aims to improve cultural safety by scaling up the Ask the Specialist training package and increasing availability of Aboriginal language interpreters and Aboriginal health practitioners at RDH, Palmerston, Gove and Katherine hospital. We will measure patient experience quantitively through self-discharge rates which is an indirect measure of cultural safety (Australian Institute of Health and Welfare, 2019), Aboriginal interpreter uptake and qualitatively through in-depth interviews in the patients first language.

Regarding study limitations, we recognise that doctors who participated in the pilot may be more receptive to this work than others. However as early adopters of the innovation (Rogers, 2003) and opinion leaders, they have the power to lead change. Interviews documenting the impact of the podcast were conducted between 2 weeks and 3 months after listening to the podcast. Further research is required to examine if behaviour change can be sustained beyond the short term. Finally, the podcast was designed to be a catalyst to inspire further learning, with weekly episodes priming listeners for reflexive discussion groups with Aboriginal healthcare users and professionals including the Specialists. The design moved away from one-off cultural awareness training to a model which encourages healthcare providers to take ‘responsibility for their own learning and to do “more work”’ through ongoing group discussions (Fredericks & Bargallie, 2020, p. 302). However due to the COVID-19 pandemic, which restricted physical interactions and placed an increased burden on providers, we were initially unable to pilot the discussion groups. As restrictions around COVID-19 eased in the NT, we have subsequently piloted the full education package. Evaluation is underway.

Conclusion

Our findings provide evidence that cultural education, which addresses the problems doctors face, delivers ‘counterstories’ from Aboriginal peoples, and encourages the development of critical consciousness, can change attitudes and behaviour of health providers. The podcast format was rated highly by doctors who also appreciated the 7-week program which allowed for cycles of listening, reflection, and action. Whilst the podcast was designed to be deliberately local and specific to the individuals and cultures represented, universal truths applicable beyond the NT and outside of healthcare were apparent to listeners. Ask the Specialist: Larrakia, Tiwi and Yolŋu stories to inspire better healthcare podcast is publicly available through Apple and Google podcasts and Spotify.

Authorship statement

All authors meet ICMJE requirements for authorship.

Acknowledgements

The authors would like to thank: Top End Health Service particularly the anonymous doctors who participated in this project and Sean Taylor for his support; Bernadette Nethercott, Curtis Roman and all staff from the NT Aboriginal Interpreter Service. We also thank the anonymous reviewers and journal editors who provided us with beautifully considered and constructive feedback. We are very grateful for their time.

Disclosure statement

At time of writing, Anna P Ralph was employed by Top End Health Service. Bilawara Lee was a member of the Top End Health Service Health Advisory Group and a member of the NT Health Ministers Advisory Committee. Alan Cass was Deputy Chair of the NT Clinical Senate. No competing interests were declared by other authors.

Additional information

Funding

Vicki Kerrigan was supported by an Australian Government Research Training Program Scholarship and Improving Health Outcomes in the Tropical North: A multidisciplinary collaboration (HOT NORTH)’, (NHMRC GNT1131932). Stuart Yiwarr McGrath was supported by HOT NORTH Indigenous Development and Training Award (NHMRC GNT 113193). Anna P Ralph was supported by an NHMRC fellowship 1142011. Alan Cass was supported by a NHMRC Investigator [grant number 1194677]. Funding to undertake data collection was provided by the Menzies School of Health Research Grants Scheme.