Closing the miscommunication gap: A user guide to developing picture‐based communication tools for Aboriginal and Torres Strait Islander peoples in emergency departments

To document an illustration‐based methodology for culturally safe communication between Indigenous patients and clinicians in an urban ED.


Introduction
Communication plays a vital role in ensuring patient safety and providing quality healthcare, particularly in highstress environments such as EDs.When miscommunication occurs, patients can suffer serious adverse health consequences.Aboriginal and Torres Strait Islander patients frequently experience miscommunication when engaging with ED staff, particularly around language use (including Aboriginal English) and diversity of dialects. 1This is further heightened in a COVID-19 environment where ED staff are wearing full personal protective equipment and patients find it hard to hear the clinicians and see their faces.
Research has shown that pictorial guides, such as cartoon illustrations, are an effective strategy for conveying information, and significantly improve patient comprehension and compliance with ED discharge instructions and patient satisfaction. 2However, the use of illustration-based techniques in ED settings is not widespread and those that are available focus on hospital discharge care and instructions. 3,4n Australia, few illustrative resources have been developed to communicate with Indigenous people seeking healthcare.There is also limited general information to support patients in the ED, and no peer-reviewed evidence describing the methodology used to develop such communication tools.
Thus, our research details both the available literature in this area and our methodology in developing a pre-ED communication tool to support the interests and concerns of Indigenous patients in a metro-urban ED in Melbourne.

Implementing the methodology
Our methodology is premised on both Indigenous and non-Indigenous methods of engagement and research (Fig. 1).
Step 1: establishing project governance Project governance involves describing and implementing functions and processes that guide a project throughout its life cycle, and defining the structured roles, responsibilities and accountabilities within the project.Successful project governance strategies with First Nations patients must include an awareness of the diversity, rights and interests of the cultural groups represented; of how they want to have their strengths, concerns and priorities addressed; and of how cultural rules and values will be implemented.
Step 2: conducting a literature review needs of First Nations patients in ED environments.After consulting with the project governance group, we chose two content areascomprehension issues and pain managementidentified from ED patient interviews in a previous research project 1 as the focus of our communication tools, and reviewed more than 40 publications about them.A further literature review explored the types and usage of available illustration-based tools to ensure that the communication tools we developed are evidence informed.
Step 3: gaining ethics approval As the research project was hospitalbased, ethics approvals were required and needed to be sitespecific, which was time-consuming and involved additional costs.This study received ethical approval from the St Vincent's Hospital Melbourne Human Research Ethics Committee (Project ID number: 79182).

Step 4: designing the illustrations
We contracted a professional illustrator to develop the illustrations.As these were to be trialled at a specific ED, the characters needed to be reflective of the hospital's location.Thus, Bunjil, the Wedge-tailed Eagle was chosen as the main character and narrator to ensure cultural local relevance and understanding among the local Koori community.
In addition to providing photos and soundscapes of the ED, we also worked closely with ED staff to develop scripts for the illustrator to ensure the resultant tools clearly explained how the ED operates and what to expect when visiting it.
Step 5: conducting the consultations and the co-design process We held two online consultations with ED staff to co-develop the content of the illustrations and present the character drafts.
From there, three scripts were developedthe process of being triaged and admitted, the content of communicating levels of pain, and the experience of a parent (as a patient) bringing their children to the EDwhich we shared with ED staff to verify their accuracy.Three online workshops were then held to obtain feedback on the drafts from  Indigenous community members, ED staff and other hospital service providers.N.B.The authors are unable to share the feedback from workshop participants as the consent forms signed did not include using their words in publications.
Step 6: finalising the illustrations The feedback was sent to the illustrator who revised the drafts several times before producing final versions of the illustrations (Fig. 2).
Step 7: contributing to the evidence and knowledge base Knowledge exchange is an important part of implementing this pre-ED communication tool, which can contribute to the evidence base in several ways.
There is opportunity, for example, to distribute these illustrations at Victorian Aboriginal community organisations that have referral pathways to hospitals and at local housing corporations.

Conclusion
To improve both the experience and health outcomes of Aboriginal and Torres Strait Islander people presenting at EDs, we need to create culturally safe and effective communication tools.This is best achieved through processes that recognise the essence of family and community relationships and why people present at EDs, and that facilitate this experience with as much dignity and camaraderie as possible.Good communication with Indigenous patients will require ED staff to learn about, understand and respond to cultural protocols.It will also require EDs and hospitals to take responsibility for venturing into intercultural spaces through committed and decisive action to address miscommunication, achieve equity and enhance access to EDs globally.

Figure 1 .
Figure 1.Methodology used to develop ED-based illustrations.

Figure 2 .
Figure 2. Examples of the illustrations developed.