Background
Communication between patients and staff is crucial for quality and safety of healthcare.1,2 Effective communication enables patients to understand their health condition and treatment options, participate with informed consent and, overall, have positive experiences when interacting with health staff. Miscommunication between patients, their family members and health professionals can have severe consequences, including misdiagnosis, procedures undertaken without fully informed consent and discontinuation of treatment with health-damaging consequences.2,3 The Australian Commission on Safety and Quality in Health Care1 have identified that communication failures are one of the most commonly cited underlying causes of adverse events.
Many different characteristics and factors impact on people's (patients, their family members and staff) ability to communicate. Contextual and individual/personal characteristics include age, education, health and mental health status, occupation, socioeconomic status, social supports, networks and previous experiences.4 Cultural factors may include a person's (and their family's) knowledge, language, ethnic background, lore, lifestyle, attitude and beliefs.1,2,5 There are also wider historic and socioeconomic factors that may impact on a person's access to education, information and knowledge. Many of these characteristics and factors may change over time.1,6 Communication in hospital takes place within a complex health system. There is increasing emphasis in the literature about the importance of improving communication and understanding in healthcare environments.7 The Australian Commission on Safety and Quality in Health Care defines health literacy as the way that people "understand information about health and health care, and how they apply that information to their lives, use it to make decisions and act on it".1(p.5) At an individual level, health literacy characteristics may include skills, abilities, motivations and capacities of individuals to obtain, process and understand health information and services provided, in order to make appropriate health decisions.1,8 Skills and abilities for health literacy include: listening and speaking (oral literacy and verbal communication), writing and reading (print literacy), numeracy, cultural and conceptual knowledge, the knowledge of when and where to seek health information, assertiveness, capacity to process and retain information and skills to apply information.4
The way the health system is organized also has an impact on communication and health literacy. The healthcare environment involves specific infrastructure, policies, processes, materials, people and relationships, and these factors have an impact on the way in which people can access, understand, appraise and apply heath-related information and services.9 The content, language and availability of resources, and timing and location of interactions between patients and healthcare providers all impact on health literacy.1,10 This environment is also positioned within a wider societal context, with political and social factors that may impact on the health literacy and attitude of individuals and services, and communication.1
There is no Australian national data available on the health literacy of Aboriginal and Torres Strait Islander people.1 However, what is known is that many Aboriginal and Torres Strait Islander people experience disadvantage across a range of socioeconomic indicators, including education, employment and income.11 Additional language barriers exist for Aboriginal and Torres Strait Islander people for whom English is not a first or subsequent language, as Australian hospital care is predominantly provided in English.3
In-hospital disparities for Aboriginal and Torres Strait Islander people related to differing levels of access and healthcare outcomes are well reported.11,12 However, there is limited knowledge and understanding of how these health outcomes relate to communication and health literacy for this population group. Research in the Northern Territory and Western Australia, focusing on the experiences of patients with chronic conditions3,5 and cancer,2 have identified significant instances of miscommunication between healthcare providers and Aboriginal and Torres Strait Islander patients. Cross-cultural communication is being complicated by the poor understanding of health professionals about Aboriginal and Torres Strait Islander culture and life circumstances, an alienating hospital environment, lack of resources and explanations in the person's first or subsequent language and lack of Aboriginal and Torres Strait Islander staff and support people.2,3 In addition, there are often very different world views and understandings of illness causation between Western medicine and Indigenous cultural beliefs related to the connectedness of the body, mind, land and spirit.5 There are also concerns raised about experiences of racism within hospitals, linked to historical events and wider ongoing colonization impacts. Some Aboriginal and Torres Strait Islander patients have identified avoiding or delaying attending hospital due to concerns about racism, discrimination and a lack of respect.2
While it is recognized that Aboriginal and Torres Strait Islander people who live in remote settings have a high likelihood of experiencing communication and health literacy issues,2,3 it is less known whether those who live in regional and urban settings may also be confronted with barriers to receiving high-quality healthcare.11 Health-literacy models predominantly emphasize the health literacy and communication skills of patients, but not of healthcare providers.
A preliminary search for existing systematic reviews related to this topic of in-hospital communication and health literacy for Aboriginal and/or Torres Strait Islander people and staff in Australian hospitals has been conducted in Cochrane Library, the JBI Database of Systematic Reviews and Implementation Reports, Centre for Reviews and Dissemination and Campbell Collaboration with no current systematic reviews located.
This systematic review will inform the "Communicate" project that explores the in-hospital communication experiences of rural, remote and urban Aboriginal and Torres Strait Islander cardiac patients, their families and healthcare providers. The "Communicate" project is funded by the Heart Foundation (Project number 100749) at the South Australian Health and Medical Research Institute, with ethical approval from the Aboriginal Health Research Ethics Committee, SA Health and the Human Research Ethics Committee of Northern Territory Department of Health and Menzies School of Health.
The "Communicate" project aims to identify specific improvements in regard to patient communication at all points of interaction through the hospital journey. The findings will be compared to current recommendations and guidelines and will become the basis of recommendations to the Heart Foundation to develop potential culturally appropriate solutions that will endeavor to improve health literacy of patients.
The outcomes of the "Communicate" project will be recommendations on how in-hospital cardiac care can be improved through enhanced communication between healthcare providers and patients and their family members accompanying them. The project will work with the Heart Foundation to produce an appropriate resource that will help healthcare providers better understand the communication challenges that Aboriginal and Torres Strait Islander patients face.
Inclusion criteria
Types of participants
This review will consider studies that have included Aboriginal and Torres Strait Islander adults who have been admitted to hospital in Australia for any health concern, their families who are accompanying them, and staff working in Australian hospitals.
Phenomena of interest
The phenomena of interest are the experiences of communication between patients, their family members and staff members, and the factors that influence those communication experiences. Communication in this instance refers to verbal and non-verbal, including written and diagrammatic information and body language. Factors that influence these communication experiences may include individual, cultural and socioeconomic characteristics, levels of health literacy, hospital environments and structures, and political/historical events.
Context
The context of the review is any Australian acute care hospital in a rural, regional or metropolitan location.
Types of studies
The qualitative component of the review will consider studies that focus on phenomenological, action research and ethnography qualitative studies; however, other qualitative methodologies will also be considered. The textual component of the review will consider expert opinion, discussion papers, position papers and other text (e.g. reports).
Search strategy
The search strategy aims to find both published and unpublished studies. The three-step search strategy to be used in this review is as follows:
An initial limited search of Scopus, CINAHL and PubMed will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English from January 2000 to the present will be considered for inclusion in this review. The year 2000 was selected to give the search a contemporary focus and also because of the rapid changes in the health system since 1990, when the term health literacy started to be used more widely.
The databases to be searched include: PubMed, CINAHL, Embase, Scopus, PsychInfo, ATSIHealth via Informit Online, Web of Science, Australian Indigenous Health Bulletin.
The search for unpublished studies will include: Australian Institute of Aboriginal and Torres Strait Islander Studies, Australian Indigenous Health InfoNet and Lowitja institute.
Initial keywords to be used will be as follows: Indigenous; Aboriginal; Torres Strait Islander; acute; patient, provider experience; staff; hospital staff; ward; emergency department; hospital; in-hospital; communication; experience; patient journey; literacy; health literacy; health education; understanding; knowledge; cultural care, patient centered.
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the respective Joanna Briggs Institute Assessment and Review Instrument (JBI-QARI) for qualitative papers, and the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) for textual papers (Appendix I).
Any disagreements that arise between the reviewers will be resolved through discussion with a third reviewer.
Data extraction
Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). Textual data will be extracted from papers included in the review using the standardized data extraction tool from JBI-NOTARI (Appendix II).
The data extracted will include specific details about the population, study method and outcomes of significance to the review question and specific objectives as available in the publication. The primary and secondary reviewers will extract data from individual studies separately. We will not contact authors for information beyond what is available in the publication, due to time and resource constraints.
Data synthesis
Qualitative research findings will, where possible, be pooled using JBI-QARI. Textual papers will, where possible, be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent the aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for improvements in practice. Where textual pooling is not possible, the findings will be presented in a narrative form.
Acknowledgements
This project is a partnership between the Heart Foundation and the South Australian Health and Medical Research Institute (SAHMRI).
Appendix I: Appraisal instruments
QARI appraisal instrument
NOTARI appraisal instrument
Appendix II: Data extraction instruments
QARI data extraction instrument
NOTARI data extraction instrument.
References