“You can do it in another way”: healthcare provider reflections on cultural safety training in Australia’s Northern Territory

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Ralph, Maddison Sims, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7826786/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Cultural safety and effective communication are essential to equitable quality healthcare. Cultural safety requires critical reflection - an active process which can be transformative when it supports a shift from awareness to practice change. Australian government departments, training organisations and regulation authorities require healthcare providers to complete cultural safety training but methods for effectively teaching critical reflection are not well described and evidence for their impact is limited. In Australia’s Northern Territory, a culturally safe communication training program called Ask the Specialist Plus (ATS+) was delivered as part of the Communicate Study Partnership. This study documents healthcare provider reflections on this locally-designed training. Methods A mixed methods approach included post-session participant surveys, pre and post training interviews, and participant observations. Survey participants provided free text responses and rated training sessions across five domains. Semi-structured interviews were conducted with purposefully sampled participants prior to the training and 3–6 months after completion. Data was analysed using constructivist grounded theory to facilitate critical inquiry. Results Data was collected from doctors, nurses, clinical managers, allied health professionals, medical imaging professionals and medical students. 337 surveys were collected, 30 interviews were conducted (15 pre-training and 15 post-training) and five staff were observed. Over 90% of survey participants agreed the training was relevant, engaging, supportive, and prompted reflection and change. Interview participants realised that their personal transformation and practice changes could make a difference to culturally safe communication and also identified departmental and hospital barriers. Reflection and action are evidenced by the gerunds and phrases ATS + participants used to describe training impacts: acknowledging, considering, reflecting, confronting, becoming aware, unpacking, interacting, building, creating, rearranging, implementing, making time, supporting, committing, realising, constraining, feeling powerless, doubting, taking responsibility and continuing. Conclusions ATS+, a locally-designed culturally safe communication training program co-delivered by First Nations and White facilitators in partnership, stimulated healthcare provider critical reflection and supported meaningful decolonising action. Learning Health System models offer pathways for addressing the structural and systemic barriers participants identified and for accelerating the translation of research into system-wide practice of cultural safety. Trial registration ClinicalTrials.gov protocol ID NCT05629416 Healthcare provider training Cultural safety Intercultural communication Anti-racism Critical reflection Learning health systems Figures Figure 1 Figure 2 Background Cultural safety and effective communication are essential to equitable quality healthcare, yet these so called ‘soft skills’ have long been undervalued within health service delivery ( 1 ). Culturally safe communication is not merely about language proficiency or respectful relationships between patients and providers - it is about creating healthcare services that do not disempower service users based on Indigeneity, gender, age, sexual orientation, ethnicity, socioeconomic status, disability or religious beliefs ( 2 , 3 , 4 ). This requires a fundamental shift from viewing culturally safe communication as an individual skillset to recognising it as a systemic responsibility of the healthcare system. On the continent colonisers called Australia, culturally safe communication in healthcare is an expectation set by government departments, training organisations and regulation authorities ( 5 , 6 , 7 , 8 , 9 ). The Australian Human Rights Commission states that to address racism in healthcare all health professionals must receive cultural safety training ( 10 ). For health services to be clinically safe, effective and contribute to achieving health equity for First Nations peoples, culturally safe communication must be prioritised and improved ( 3 ). However a gap remains between policy and practice ( 11 ). Teaching cultural safety is challenging and evidence for its impact is limited ( 12 , 13 , 14 , 15 ). A recent paper observes that healthcare providers and services must be culturally competent as well as being culturally safe ( 2 ). To be culturally competent, individuals or an organisation must recognise and respect that patients may have different worldviews to the hegemony and adapt behaviours and services to deliver equitable health outcomes for all ( 2 , 16 ). Cultural safety “focuses on the analysis of how power and privilege are distributed (among professionals, patients and organisations)” (2, p7). The extent to which cultural safety is achieved is determined by patients but responsibility for critical reflection and change rests with providers and institutions ( 4 , 17 , 18 ). To create a culturally safe health service for First Nations peoples in colonised countries such as Australia, Aotearoa New Zealand and Canada, transformative decolonial action must be taken by healthcare providers to minimise the dominance of Whiteness in healthcare systems ( 4 , 16 ). Cultural safety requires critical reflection, which in turn builds critical consciousness ( 17 , 19 ). Critical consciousness supports a respectful approach to communication that reduces stereotypical thinking which manifests as racism ( 20 ). Critical reflection is an active process and can be transformative when it supports a shift from awareness to practice change; it entails deep examination of one’s worldviews and assumptions as well as a focus on how power is used to maintain or challenge systems at personal and institutional levels ( 21 , 22 ). Methods for effectively teaching critical reflection are not well described in existing literature, although ‘counterstories’ from structurally marginalised peoples have been advocated by Critical Race Theorists as an effective strategy ( 23 ) and there is evidence of their transformative potential ( 24 , 25 , 26 , 27 ). In Australia, the shared history of Western medicine and colonisation contribute to First Nations peoples feeling unsafe and disrespected when seeking healthcare ( 28 ). Patients report confusion, aggression from healthcare professionals, interpersonal and institutional racism, treatment without consent and pressure to abandon cultural protocols, resulting in high rates of unplanned discharge from hospital, inequitable treatment, poorer health outcomes, distress, and avoidable mortality ( 3 , 11 , 13 , 29 , 30 , 31 ). Conversely, when patients feel culturally safe, health outcomes are likely to improve, trust in health services grows and there is less demand on health services because there is a reduction in repeat presentations ( 31 , 32 ). Benefits also flow to healthcare providers. Healthcare providers have expressed a desire for more training that supports the delivery of culturally safe care ( 33 ) which has been shown to increase professional satisfaction for non-First Nations staff ( 19 ) and interpreters ( 34 ), thereby potentially reducing burnout and staff turnover ( 35 ). These issues are of great relevance in Australia’s Northern Territory (NT) where most healthcare users identify as First Nations but the majority of healthcare providers are not. At the 360 bed Royal Darwin Hospital (RDH), the NT’s largest hospital located on unceded Larrakia country, approximately 70% of patients and 7.8% of staff identify as First Nations ( 36 ). The NT is linguistically and culturally diverse with approximately 100 Aboriginal languages and dialects ( 5 , 37 ). 58.5% of NT First Nations peoples speak an Aboriginal or Torres Strait Islander language at home ( 38 ). The NT has a high proportion of short-term healthcare staff from interstate or overseas, many of whom are unprepared for the complex medical environment of the NT, have limited knowledge of the unique richness and diversity of First Nations cultures, and – primed by stereotypes and negative perceptions of First Nations peoples – may experience culture shock and a sense of hopelessness while struggling to provide care that is culturally safe ( 3 , 19 , 39 , 40 ). The Communicate Study Partnership ( 41 ), which includes First Nations health professionals and community leaders and non-Indigenous health and communication practitioner-researchers, developed a locally designed, culturally safe communication training program called Ask the Specialist Plus (ATS+). When the training was conceptualised and delivered, there was no other cultural safety training offered to NT health staff beyond this project. ATS + consists of two components. The first is a podcast of seven 18-minute episodes titled Ask the Specialist: Larrakia, Tiwi and Yolŋu stories to inspire better healthcare ( 42 ). The podcasts are based on the Freirean concept of ‘problem-posing education’ ( 22 ) and the Critical Race Theory concept of ‘counterstories’ ( 43 ), with doctors articulating questions which are then presented to the First Nations Specialists to provide their perspectives ( 27 ). Doctors reported attitudinal and behavioural changes, inspired by critical reflection, after listening to the podcasts ( 44 ). The ‘plus’ of ATS + refers to weekly training sessions to encourage healthcare providers to engage in critical reflection, with groups co-facilitated by First Nations and White facilitators. This approach encourages dialogue, elevates marginalised voices, and recognises that the descendants of both coloniser and colonised share responsibility to dismantle racism ( 22 ). In 2021, ATS + was piloted at two RDH departments and evaluated through anonymous surveys ( 45 ). Participants reported impacts on thinking, knowledge and behaviour; 90% of participants were satisfied. However the evaluation was limited because surveys lack the nuance and depth that can be found in qualitative data ( 46 ). Considering the aim of the training was to enhance healthcare providers capacity to critically reflect, further research was needed. Subsequently, in 2023, The Communicate Study Partnership was contracted by NT Health to deliver ATS + to a larger cohort across the Top End. This paper reports on a qualitative evaluation of healthcare provider perspectives of the expanded ATS + program. Terminology In this study, First Nations is a collective term used for the sovereign first peoples of the place now called Australia, inclusive of diverse nations of Aboriginal and Torres Strait Islander peoples. Throughout the paper, the word White has been used to refer to people who do not identify as First Nations. This word has been used by researchers to describe themselves and also by participants who learnt about Whiteness in the training. In this context, White helps to “counter the invisibility of race within the dominant population that is implicit in terms such as ‘non-Indigenous’” (47, p369). Bargaille ( 47 ) defined Whiteness in Australia “as a system of power relations that privileges non-Indigenous peoples over Indigenous Australian peoples” (47, p19). In Australia, White refers to a social category beyond observable characteristics which describe individuals who, knowingly or unknowingly, participate in a racialised society that positions them as superior or White in comparison to First Nations peoples ( 47 , 48 ). In using this term in this manner, we also acknowledge that colonialised Australia is culturally and ethnically diverse, and that participation in White society in Australia does not preclude experiencing racism and discrimination. Finally, White is capitalised not to indicate dominance, but to show that this is a socially constructed racial category and to challenge the often-used approach of only attaching the concept of race to minorities. Methods Researcher backgrounds EA is a White Australian intercultural communication researcher and a speech pathologist who works collaboratively with First Nations Australian researchers and communities. TA is an Alawa and Marra woman from Darwin, NT, and early career research assistant at Menzies School of Health Research with experience in community-based health programs. MH is a White Australian qualitative health researcher who has lived and worked in the NT for over 10 years. APR is a White global health researcher and infectious disease clinician at RDH. MS is a White Australian global health professional living and working on Larrakia land. EJ is a White Australian and has been working as a health care professional in the NT for over 15 years. CC is an Aboriginal man from Larrakia Country; his 20-year career spans frontline healthcare delivery to executive level positions developing policies. VK is a White intercultural health communication researcher and practitioner, and was the only White co-facilitator of ATS + discussion groups. Study Design The Communicate Study Partnership (ClinicalTrials.gov ID NCT05629416) was developed to support the delivery of culturally safe healthcare in the NT( 11 ). The study is grounded in constructivist concepts of cultural safety ( 4 ), Critical Race Theory (CRT) ( 43 ) and Freirean pedagogy ( 22 ). An underpinning principle is the need to redress power imbalances between non-First Nations healthcare providers and First Nations peoples in hospital. The implementation research aims to stimulate critical consciousness among healthcare providers through dialogue which centres the voices of First Nations peoples. Intercultural communication training for healthcare providers has been developed as one way to address inequitable power dynamics that can manifest in clinical encounters ( 11 ). By equipping healthcare providers with skills to communicate more effectively across cultures - particularly in ways that acknowledge ongoing colonial impacts - intercultural communication training offers a practical approach to improving relationships, building trust, and delivering more equitable, person-centred care. Consistent with a Learning Health System framework ( 49 ) the aim of the overall research program is to generate new knowledge about culturally safe communication training and its impact on staff, to enable learning which can be operationalised across NT hospitals. Training design The ATS + training consisted of 8 x one-hour sessions delivered weekly over eight-weeks to specific RDH departments. Training was designed for face-to-face delivery with an online option for those unable to attend in-person. Sessions were rostered to suit department teaching time. Each week focused on a specific topic (Table 1 ), reflecting the 7 podcast episodes and an introductory module on cultural safety. Additional details about training design and delivery have been published previously ( 45 ). Table 1 ATS + session topics Week Topic 1 Cultural safety introduction 2 Get to know your patient 3 Communicating with your patient 4 Communicating with interpreters and your patient 5 Patient-centred care 6 Informed consent 7 Recognising and addressing racism 8 Perspectives on health and well-being Data collection and sampling A mixed methods approach was planned comprising post-session participant surveys, pre and post training program interviews, and participant observations. All participants were asked to anonymously complete paper based or electronic surveys (accessed via a QR code) at the end of each session, as we have used previously ( 44 ). Participants rated sessions across five domains using a 5-point Likert scale: content relevance to their work; the extent to which the session prompted reflections on attitudes; planned behaviour change; perception of facilitators; and attitudes towards session duration. Free text responses could be included. Participants were also invited to engage in semi-structured interviews either in-person or online with EA, TA, MH or EJ prior to the training and 3–6 months after completion (Interview guide: see Supplementary material 1). Staff from participating departments were purposefully sampled ( 50 ) to ensure a diversity in professions, length of experience in the NT and seniority. In pre-training interviews participants discussed their: personal and professional culture; experiences of working with patients who identify as First Nations; reflections on hospital culture and systems; approaches to communicating with patients; understanding of cultural safety and their roles in it. In post-training interviews guiding topics included: feedback about the training content, format, duration, delivery and facilitation; reflections about how participants felt post-training; stories about if and how ATS + had influenced their interactions at work; facilitators and barriers to implementation of what they had learnt through the training; what participants plan to do next. Participants were encouraged to raise additional relevant topics. Interviews were conducted in English, audio recorded and transcribed. Participants were also asked if they would agree to being observed at work before or after interviews, with the consent of health service users. A form was developed to record observations about culturally safe practice. Data analysis Constructivist grounded theory was used to facilitate critical inquiry ( 51 ). This is consistent with the aims of the Communicate Study’s transformative paradigm and aligns with principles of CRT. Interview transcriptions were inductively coded line-by-line by EA, TA and MH using gerunds (“-ing” words) to explicate processes of transformation ( 51 , 52 ). Codes were then grouped into categories. Observational data was analysed by MH. Electronic quantitative survey results were downloaded from SurveyMonkey in a Microsoft Excel spreadsheet and paper surveys were scanned then entered into the same spreadsheet, organised by training week and department. MS then generated descriptive statistics for each question by calculating the proportion of responses corresponding to each score (1 to 5) and averaging these proportions across all weeks within each department. Free-text responses were collated into a Word document each week, keeping responses connected to participants’ professions but not otherwise identifiable. Free text responses were categorised by TA and reviewed by EA. Co-authors EA, TA and MH met regularly to compare codes, identify commonalities, and iteratively develop themes. As themes were generated, the team developed a conceptual map to locate and analyse the impact of the ATS + program at different operational levels: personal and interpersonal, departmental, and hospital/systems level. This aligns with a Learning Health System framework which recognises that for a health system to effectively apply research findings, changes must be implemented at the micro, meso and macro levels ( 53 , 54 ). Findings were further refined through discussions between EA, TA, MS and VK. All authors were involved in iterative rounds of paper drafting and feedback. Results Training was delivered between January and August 2023 and data was collected between November 2022 and November 2023. A total of 192 healthcare professionals from 8 departments based at RDH, Palmerston Regional Hospital and Gove District Hospital attended at least one session of ATS+ (Table 2 ). 337 surveys were collected immediately following training sessions. Thirty interviews were conducted, 15 pre-training and 15 post-training. Twenty-one different healthcare providers participated in interviews, with nine available to complete both pre- and post-training interviews. Five staff were observed; data supported participant interviews but did not reveal new or different insights. Data was collected from doctors, nurses, clinical managers, allied health professionals (including pharmacists, physiotherapists, occupational therapists, speech pathologists), medical imaging professionals and medical students. Quotes are attributed by professional group and seniority but specific details on role and work locations have been omitted to protect identities. Table 2 Participants and attendance at training Cohort Dates Sessions Total enrolled Attendees per session** (mean) In person attendees (%) Allied Health January 2023 – March 2023 8 23 13 Not collected Renal, Infectious Diseases, Endocrinology, Nuclear Medicine February 2023 – March 2023 8 60 27 73% Paediatrics, Obstetrics & Gynaecology, DonateLife* June 2023 – August 2023 7*** 109 33 53% *Organ and donor tissue coordination unit **in person and online *** Weeks 2 and 3 were combined due to departmental requirements. Over 90% of participants agreed or strongly agreed the training discussions were relevant to their work, that sessions prompted reflection on attitudes and that the facilitator styles were engaging and supportive. Similar proportions agreed that they planned to change their approach to working with patients and families, and that the duration of the discussion was perfect. Least agreement was found in relation to duration of sessions (45% strongly agree, 45% agree; Fig. 1 ). Some participants said the one-hour sessions were practical in their work day, others suggested that longer sessions would be more valuable and many requested more or ongoing training and support as they implemented what they had learnt. Some struggled to attend face-to-face training regularly due to constraints of a busy work environment but appreciated being able to engage with the ideas by listening to the podcast at a convenient time. Developing critical reflection and prompting change Participants used gerunds to describe the active processes they experienced which resulted in shifting from awareness to practice change. Participants reported change across four nested spheres of influence (Fig. 2 ): personal transformation, practice change, departmental culture, and hospital culture and systems. The arrows in Fig. 2 represent two themes that cut across these four spheres. The theme of ‘realising I can make a difference’ was strongest in relation to personal transformation and weakened as individuals identified departmental and hospital culture and systems as barriers. Reciprocally, ‘feeling powerless to make changes’ was weakest in relation to personal transformation and increased in relation to departmental and hospital culture and systems. Gerunds were centred in data analysis and are used to present the results (see Fig. 2 and below subheadings). Personal transformation: acknowledging, considering, reflecting, confronting, becoming aware Acknowledging Pre-training, many acknowledged the importance of cultural safety. This was evidenced through their commitment to attend the voluntary training program and demonstrated in their willingness to critically reflect. An allied health provider said when they started work they received an orientation booklet for the region, and asked some colleagues questions about culturally appropriate behaviour, however they still felt unprepared to support patients which motivated training attendance “Because I’m incompetent at the moment. Honestly, I’ve never worked in this area before, in this location and with these population groups. So I haven’t had any experience before, so I definitely need to try and upskill.” (Allied health provider, pre-training interview) Participants with varying degrees of professional experience said the training stimulated their desire for personal transformation and reported that ATS + allowed them to critically reflect on what they don’t know. More experienced healthcare providers reflected on the impact of the training, describing a shift in perspective and desire to change practice that came from engaging with the podcast and group discussions: “I thought I had a really good knowledge with our client group, but… it wasn’t until I started really listening to the podcasts and coming to the group that I actually thought, ‘Oh, my gosh, there’s so many things I could improve on’. And I think each week there was always usually some kind of take-home message, ‘go and try this out.’” (Team leader, Allied Health, post-training) Many participants acknowledged that the facilitators’ communication styles helped to prompt critical reflection. In the week 7 survey, a medical student described the training as “very stimulating and at times too thought provoking but overall it is helping me reflect”. Participants found sessions particularly useful and engaging when First Nations facilitators shared their lived experiences. For example when Aboriginal Liaison Officers and Aboriginal Language Interpreters discussed their work in Week 4, one survey respondent wrote: “Could have listened to interpreters all day. Very glad it was pretty much all listening to them and the discussion. Very very helpful.” Considering : Before ATS+, participants from dominant cultural backgrounds were commonly taken-aback when asked to consider their own personal and professional cultures and roles in the healthcare system. A senior nurse said: “I am as boring as they come. I think my grandparent’s grandparents were convicts… I’m very pale.” After ATS+, most reported growing awareness of how their own culture can impact patient interactions. This was particularly poignant for participants who belonged to the dominant colonising culture. After completing the training, one allied health provider realised: “I’ve been brought up in a White world with White institutions. … Until they [facilitators] said that, I’d never even considered it.” In a pre-training interview, a doctor considered the dominance of Whiteness in healthcare and expressed concerns that matched the training content: “This year was probably the first time I’ve really held up a mirror to what am I bringing to this interaction?… It was almost like cultural whiplash… The mirror that I held up to myself was that our public healthcare system is built for White health focussed populations, it’s like, unfortunately, a deeply racist framework of care. … And it’s hard day-to-day to operate in that, knowing that… the fundamental way we deliver healthcare is based on our set of priorities and not theirs.” (Doctor, pre-training interview) Reflecting : The training encouraged participants to reflect on, and discuss, the often-unacknowledged power dynamics between patients and providers. A senior doctor wrote in the week 1 survey: “Understanding the complexity & power-imbalance where I work is necessary to have an impactful therapeutic relationship.” For one senior nurse, it was “a punch in the guts” when they realised that, due to their personal and professional background, they have capacity to exert power over patients which can contribute to inequitable healthcare delivery: “Personal reflection of my own power imbalance was a bit of a punch in the guts kind of feeling… I’d never considered myself to be anyone in a position of power within the workplace… it was a different way to think about cultural safety that I think was really good. …you’re not just trying to learn stuff but actually trying to think through the implications about that existing power imbalance.” (Senior Nurse, post-training interview) Several participants reflected that the training helped them identify that their teams were already practicing culturally safe person-centred care including conducting holistic assessments, advocating for patient priorities, and using interpreters to ensure patients were informed about treatment before consenting or declining. These reflections made them proud and gave team leaders a chance to encourage staff to continue with the positive work. Confronting Some said the training was confronting and made them feel uncomfortable. This occurred particularly in the first weeks when complex concepts including Whiteness and racism were discussed. “There was this moment that I thought was really powerful. Vicki [one of the White facilitators], this is in the first week, she asked people to describe their culture… and people couldn't do it. It was that idea that if you're a white person you don't have a culture because we're the norm. So… there was an awkward silence in the room and then she put a slide up that talked about Whiteness and White culture. I know, I think, a lot of people were confronted by that. But, what an important discussion to have!” (Team leader, Allied health, post-training interview) Some participants also felt uncomfortable when asked to consider that all White people are “foreigners” living on unceded lands of First Nations people. This idea was shared by Tiwi Elder Pirrawayingi Puruntatameri in the podcast and repeated by facilitators. For those who continued attending, this discomfort shifted over the sessions, for example in week 1 a participant wrote in a survey that they felt “a lot of blame” particularly from the White facilitator but in week 2 someone from the same team wrote: “This felt better than last week - didn’t feel as pointed at us as the problem but part of the solution.” (Medical imaging professional, week 2 survey) The training supported participants to confront racism as both interpersonal and systemic. Some reflected deeply on their own roles in perpetuating or challenging racism. An Allied Health provider wrote in the week 7 survey: “I am getting better at self-reflection despite often feeling very uncomfortable at discovering my level of racism/bias/white privilege.” In a post-training interview, an allied health provider reflected on the commonly held misbelief among colleagues that racism is predominantly overt acts of discrimination and hate: “I think it's the slow-moving recognition of what racism is and what racism might not be. And actually that was a big thing for me to try and work out. Racism isn't just calling people racist things. It's our healthcare - there is so much racism everywhere. It doesn't actually have to be something offensively called, but some people still are stuck there and not open to change and it's sad.” (Allied health provider, post-training interview) Becoming aware Participants became aware of the challenges faced by people from remote First Nations communities, especially the impacts of leaving home for healthcare. As they became aware of the reality of seeking healthcare for many of their patients, they changed their practice by working more with patients and families to shape rehabilitation goals and advocated for better discharge planning. Many became aware of the need to partner more with Aboriginal Liaison Officers, Aboriginal health professionals, interpreters, families and patients themselves. However, some recognised that there aren’t enough First Nations staff to meet needs. “I know from Ask the Specialist [podcast] now we can't expect that this work just sits with Aboriginal people, but how can we do it hand in hand? It's very hard when we're a team of White people.” (Allied Health provider, post-training interview) As participants developed a deeper awareness of cultural protocols that shape communication within and between cultures, including the range of First Nations languages understood and spoken by patients and the complex demands placed on interpreters, they began to deepen their understanding of how intercultural communication challenges can impact patient outcomes. After the training, many were aware of how ineffective communication contributes to culturally unsafe outcomes such as patients missing appointments. Others began to recognise that White communication practices, such as asking a long list of questions, can contribute to culturally unsafe interactions. One participant recalled a difficult encounter with a patient that was confusing at the time but took on new meaning post-training: “Basically, they got really upset with me, just for asking... They got actually quite angry. But I hadn’t really said anything offensive, I think I had only prompted a question about ‘Hey, where do you get your medications from?’ or ‘Did you bring any of your medicines in?’. Anyway, but this person got quite upset, called me a few things and pretty much pulled the blanket up over their head and that was the end of the interaction... (Now) I think what would’ve happened to that patient is I was probably the sixth person to walk through that morning and bother her with questions about things.” (Allied health provider, post-training interview) Practice change: unpacking, interacting, building Unpacking Participants shared positive stories of individual practice change as they unpacked what they’d learnt, reflected on their roles and realised they could make a difference to patient experiences. Many began to unpack the facilitator’s suggestion that dehumanising language used in healthcare - such as “compliant” and “non-compliant” which can imply the patient is the problem – should be changed. One participant highlighted how deeply embedded such language is, acknowledging the challenge of finding alternative ways to communicate about patients in fast-paced work environments. “Some of the language we use around patients and labelling people as compliant, non-compliant, non-adherent, stuff like that, it is very difficult to explain a situation without using a word like that… in a really quick way, without saying one of those words … sometimes I would sit there [in the training] being like, ‘well we can't do it any other way’. (But) You can. You have to take more time to do it, you can do it in another way. But I think it takes you to talk through in front of other people and your peers … Because you actually end up having to say things out loud and practice what you preach.” (Allied health provider, post-training interview) Interacting The training supported participants to change how they interact with patients. Before the training, there was wide variation in participants’ awareness of First Nations languages and of potential impacts of linguistic diversity on healthcare interactions. When asked if they could name any First Nations languages, one participant had difficulty pronouncing the three languages they could name and said “I’m not going to go any further… I mean I know places fairly well, because I like maps so I do look at maps. But I’ve never been the person to request an interpreter. And I feel as though I don’t usually ask people what language because either it’s written down or – you know, it’s not something I think to ask somebody, so I would not be confident.” (Senior nurse, pre-training interview) Pre-training observational data indicated a lack of involvement of interpreters in patient-provider interactions. After the training, many participants reported changing their approach. This included checking the patient’s language, accessing interpreters, and being more confident with booking an interpreter. A doctor reflected that they had not appreciated the crucial role of interpreters until the training. They described having their “mind blown on several occasions” when they thought they were communicating reasonably well in English but then, the extent of miscommunication was revealed when an interpreter was involved. After completing the training, an Allied Health provider said they advocated for a patient to access an interpreter, despite resistance from a colleague, and saw positive outcomes as a result: “I went to do some discharge counselling and… I was like [to a nurse], ‘Oh, I want to organise an interpreter for this discharge.’ The nurse had been like, ‘Oh no, he speaks fine. Don't stress about that.’ But then I was like, ‘Oh no, I think if someone's documented it, it's probably worthwhile following through.’ So I still organised it and it was good because … when I went in, we talked about the medicines and I don't speak any language, but I could kind of tell that she [the interpreter] was expanding into, when she was talking about the heart, she was using lots of really cool analogies, which I wasn't really thinking - I had never thought about before.” (Allied health provider, post-training interview) Participants discussed changing their communication styles to be more culturally congruent with patients. They discussed using multimodal communication strategies (e.g. images, models, analogies) to make information more accessible. Participants applied these strategies across all stages of patient journeys, from taking a case history to discharge or end of life planning. One participant recounted a meeting with a patient from a remote community and their family to discuss the patient’s end of life plan. The participant implemented what they learned: they consulted an interpreter before the family meeting to get advice on how best to conduct the meeting and the interpreter suggested using drawings and models to enhance communication and allow the family time to consider what was being explained. The clinician felt these changes improved the interaction: “(I) just really explained everything in a really careful way with lots of pauses, lots of space for silence… and really expressed my sorrow. It just felt like a really positive experience, which is a horrible thing to say when it’s someone’s death, but it just felt really compassionate, considered and respectful and the family really seems to appreciate it too.” (Doctor, post-training interview) Building Over the course of the training, some participants described building confidence to implement small but impactful new strategies and increased work satisfaction when they observed positive patient responses. An allied health professional said they “felt almost embarrassed” about some previous patient interactions after they saw the difference it could make to change one or two things within their control. A nurse had a similar realisation regarding the cumulative impact of making small changes over time “If you make an effort [to learn about communicating], someone else will make an effort back. It doesn't have to bridge the whole lot, but it just has to be little tiny steps, and then eventually you go, hey, look what we've done in six months! Like, looking back, now we've actually achieved a lot I think.” (Senior nurse, post-training interview) The training session on building rapport with patients was particularly valued by participants who implemented strategies learned. When introducing themselves to patients, some participants started to share personal details about their own lives, for example using maps on their mobile phone to show patients where they come from. Others developed rapport by trying to “find common ground first”, for example, finding people they know in common. While these practices sometimes felt strange to participants who had been taught to maintain a professional distance in the White healthcare system, many were willing to try, and subsequently built their confidence with the new practices and began sharing the ideas with colleagues. One participant said the training provided them with an understanding of why some interactions “weren’t working” and strategies to use in these situations: “it taught me that there are solutions, there are ways around it, so it's not just dismiss it and that's the end of that interaction with that patient... And the interactions are better and I do find it more rewarding as well, building rapport with patients… It helped me provide better healthcare which ultimately is the reason I get up to do my work every day.” (Allied health provider, post-training interview) Departmental culture and practices: creating, rearranging, implementing, making time, supporting, committing Creating Participants spoke about wanting to create a sense of shared purpose and direction in their departments that reflected the principles learnt through the training. Participants became increasingly aware of departmental cultures – both the strengths and the challenges of changing practices. Some spoke about the benefits of completing the training with their team, which helped create an anti-racist culture and generated staff support for implementing changes across their department. “if you know that a lot of people have had this training, you maybe are able to have trust in your colleagues... I feel like it probably gets a little bit political in a sense, but knowing that, I think it would be good to know that everyone's had the opportunity to consider those things.” (Allied Health provider, post–training interview) Rearranging and implementing Before training, researchers observed that hospitals were not well set up to be supportive of culturally safe interactions. After training, participants began rearranging spaces and improving departmental processes. Some spoke about changing outpatient clinic set-ups “to be more patient focussed”. Others created meeting spaces outside the cold hospital building so that patients might feel more comfortable. First Nations art was displayed to make clinical spaces more welcoming in some departments and others worked on implementing changes to support the building of rapport. In one department, landscape photos taken by staff when travelling through the NT were framed and hung with information about each staff member as a way of sharing personal stories from staff and to display Country. Another department arranged mutual learning sessions between healthcare providers and interpreters as an initiative to improve culturally safe communication. These sessions led to changes in the way clinical procedures were explained, for example changing specific words with dual meanings that could be misinterpreted such as dye / die. Making time During observational data collection, the systemic pressures that restrict providers from making time to practice culturally safe communication were documented. A senior nurse spoke about time pressures to move quickly, and conversely, the rewards of making time which allowed for embracing silence in clinical encounters, highlighting its significance in culturally safe communication “Look, you don't have time to allow it, and I can tell you, there are so many reasons that it's hard to have that silence. But once you've found the skill to be able to sit in the silence comfortably in yourself, you actually get way more out of the patient.” (Senior Nurse, pre-training interview) After completing the training, another senior nurse spoke about how they learnt to work quickly because that was hospital culture: “just always be pushing – being productive”. However they observed that the pressure to be efficient was sometimes “self-imposed”, acknowledging that they work in a smaller department and therefore may have autonomy to change how they work: “So I probably have more power to change some of that than other people who work in bigger departments do… We’re constantly expecting more and more of staff… but maybe expecting less of staff would mean that people had a bit more time for patients.” (Senior nurse, post-training interview) Supporting and committing The support of departmental leaders was appreciated by participants, both in terms of “being taken off the floor” to attend training and committing to changes to improve cultural safety across a department. Training attendance by senior staff also demonstrated their prioritisation of cultural safety. “(I said to my team) we have the training at 8.30 so you’ll be starting then…I think they knew I wasn’t budging on it and that I had support from the [department head] that this was our priority. … then they turned up and we would chat about it afterwards and it was very positively received and I can see their change in practice has been really positive.” (Team Leader, post-training) Some participants highlighted systemic barriers to participation in ATS + due to the program being non-compulsory and run during their lunch break. Systems pressure and the lack of support from some managers led to some participants dropping out: “I think with attendance dropping off, some of that for people was just pressure from their work area to cover the wards… we’re always going to be busy and it's an hour [once a week for 8 weeks]… being busy, it's often been used as a reason not to engage more in-depth with this sort of learning.” (Team leader, post-training interview) Hospital systems and culture: realising, constraining, feeling powerless, doubting, taking responsibility, continuing Realising Participants realised how White Australian hospitals are and developed more nuanced understandings of the systemic factors affecting First Nations peoples' experiences of healthcare. “ATS + taught us to think about it in a way where you can go ‘Oooh wait. You know, it’s not me specifically and I shouldn’t take offence to that.’ But it’s all of these things that are impacting them [First Nations peoples] when they come into a hospital service that’s pretty much set up for any white culture to come in and get all the benefits and treated well. But anyone who’s outside of that scope, it’s quite challenging to navigate.” (Allied health provider, post-training interview) One senior nurse raised concerns that racism and a lack of healthcare provider communication skills created a “double standard” of healthcare across the system: “I do think that the colour of your skin, the language that you speak and where you come from does have an impact on your health outcomes. Which is really sad… We aim to provide good care for everyone. I don't think it's intentional a lot of the time, but I do think it's a double standard.” (Senior Nurse and Team Leader, pre-training interview) Some participants realised the heavy demands that the First Nations workforce carries working in a White healthcare system: “[My colleague] just made me realise … the culture of our organisation. … How White all our systems were. And just as an Aboriginal person in a predominantly White work unit, just how isolating, how hard that can be.” (Team Leader, Allied health, post-training interview) Constraining and feeling powerless Post-training, participants discussed how hospital cultures and systems constrain their ability, and sense of power, to sustainably implement culturally safe practices. While a few participants in senior medical positions felt they had some influence over systemic issues, junior staff reported feeling particularly constrained and frustrated. One leader said that “the hospital is just so big” and when asked about large-scale changes to create environments that are more comfortable for First Nations peoples, said “I don’t know how they can change that.” Many reported that cultural safety is not prioritised in healthcare systems. Evidence for this included lack of measuring or monitoring quality of intercultural communication, particularly compared to other performance indicators: “There’s no audits on it. There’s no KPIs on it. The hospital audits all the paperwork, they audit your notes, they audit forms, they audit your charts, and you get feedback and you have to meet targets, like hand hygiene and all of that… (but) it’s not on the radar for reporting how good you are at communicating with your patients.” (Doctor, post-training interview) Time and understaffing were frequently-mentioned constraints that left participants feeling powerless to influence systems or create change. One participant reported that understaffing requires her to take responsibility for systemic and administrative issues, limiting her opportunities to build relationships with patients: “We are usually understaffed, comparative to the amount of patients there are. So, we're usually dealing with backend problems… most of the time that kind of ends up trumping us to be able to just sit down with patients and talk.” (Allied health provider, post-training interview) Doubting Many expressed doubt about how much impact the training could realistically have within a racist system. One doctor acknowledged that while the training had a positive influence, their ability to apply lessons learned was constrained by structural issues such as chronic hospital pressures and internal emergencies, limiting time and space for culturally safe care. This doubt was particularly strong when participants considered the difficulties of addressing inherent power imbalances between patients and providers “I don’t know how you necessarily get away from that [power imbalance] in a hospital setting. I feel like it’s not an environment that’s conducive to being really much else.” (Senior nurse, pre-training interview) A junior doctor doubted the capacity of senior staff to lead change and instead said that changing culturally unsafe systems would need to be addressed by their own generation of staff as they progress through the hierarchy: “my experience of the racism that I’ve seen in my five months of being in the Territory has been generally coming from a generation above me, generally doctors who seem to place the burden of responsibility and the burden of fixing these systemic issues back onto First Nations people. I think myself and the younger cohort of doctors, nurses, allied health workers, have this attitude of politely, we’ve just, our dominant culture has just f#%*ed over the Indigenous people of our country. So, we should come from that very humble place and not expect them to pull themselves up single-handedly because we have done the damage.” (Junior doctor, pre-training interview) Taking responsibility and continuing Participants recognised the need to take responsibility for change and continue to learn. Some suggested that it may be possible to change racism throughout healthcare if all people working within the system participated in training like ATS+, including university students, early career health professionals, experienced clinicians, leaders, administration staff, transport staff, cleaners and other professionals. Many thought ATS + would be a valuable addition to the extensive list of essential training. Some believed the training should be completed before new staff interact with patients, while others recognised the value of doing, or repeating, the training once staff were familiar with the work context and patient groups. “Compared to some of the essential training we do, it’s shocking that it [ATS+] isn’t considered essential training, and it’s really powerful training, because it affects you. I know it is confronting for some people, but it does affect your life. It’s not just clinical, it’s how you see yourself in the system, and it’s not just the hospital system, it’s like a societal system that’s oppressive. And I guess that part is confronting… One of my favourite podcasts was around recognising privilege and structural racism, and using terms that a lot of White people find confronting, or invokes white fragility, but I’m at a point now where I think those lessons and those terminologies are very important to say and feel, and they’re powerful words, they’re important words.” (Senior Nurse, post-training interview) An important insight for many participants was the realisation that becoming a culturally safe practitioner is an ongoing, often cyclical journey, not a competency with an endpoint that can then be ‘achieved’. Many requested repeated and ongoing access to the training to support cultural safety in the hospital: “I think White people do this a lot… we go, ‘I’ve been to a cultural safety course, and I have listened to the Ask the Specialist podcast, so I don’t need to do this anymore. I’m trained.’ Like it’s a very White, Western, empirical medicine, you’ve done the training, you’re now competent, you don’t need to do it again. And I think that was the most powerful thing that came out of that for me, was like it never ends. We need to keep doing it… Learning that I’m a White person, I work in a White system, like it’s very easy for me to do the training and then forget that training (because) I’m working in a system that doesn’t support improving communications with First Nations people. It doesn’t prioritise it.” (Senior Nurse, pre-training interview) Discussion This study provides detailed evidence of how Ask the Specialist Plus training developed participants’ capacity to critically reflect on their power and privilege as healthcare providers working in NT hospitals, extending on previous evidence ( 44 , 45 ). Importantly, through pre and post interview design, this study also provides evidence of participants implementing changes over time and practicing what they learned about improving the cultural safety of healthcare provided to First Nations people. Reflection and action are evidenced by the gerunds and phrases ATS + participants themselves used to describe training impacts: acknowledging, considering, reflecting, confronting, becoming aware, unpacking, interacting, building, creating, rearranging, implementing, making time, supporting, committing, realising, constraining, feeling powerless, doubting, taking responsibility and continuing. These outcomes of critical reflection and transformative action are central to overturning the dominance of Whiteness and decolonising healthcare systems ( 4 , 16 ). This research fills an important gap in evidence for impacts of cultural safety training ( 14 ). Previous cultural safety training programs have struggled to encourage critical reflection, for example because medical students describe themselves as concrete thinkers and expect to be offered a list of solutions ( 55 ). Our findings indicate healthcare providers can be supported to challenge such expectations when training is designed to both encourage and confront participants. We found that a careful balance between challenging material and practical strategies can facilitate productive participant critical reflection on complex concepts such as Whiteness, racism and power dynamics. This finding aligns with studies which have found that a challenging, uncomfortable or confronting trigger can be conducive to critical reflection, particularly when disquiet is paired with a supportive context for guided interaction with peers and teachers ( 55 , 56 ). Participants in this study appreciated learning from the lived experiences of First Nations facilitators. However, we advocate that training should continue to be facilitated by First Nations and White facilitators working in partnership, recognising both the expertise of First Nations facilitators and the responsibilities of White partners to address systemic inequities. This collaborative approach reduces the risk of this work becoming an unmanageable, unwanted and uncompensated cultural and colonial load for First Nations staff ( 2 ). Support for the health and wellbeing of facilitators undertaking this confronting work must also be prioritised ( 57 ). This study demonstrates the value of supporting staff to recognise that they have previously been educated in a White biomedical communication style and that they have the power to change their approaches to better align with patient communication norms. ATS + training provided participants with strategies for making these changes based on suggestions from First Nations participants in previous studies ( 31 , 58 ). Ongoing, meaningful, coordinated partnerships with those who have experienced healthcare inequity can support hospital staff to challenge the White systems which create and perpetuate inequity, mindful that equitable co-design requires significant time, strong relationships and specific skills ( 53 ). Consistent with past research ( 33 , 45 ), many participants suggested that ATS + should be mandatory and ongoing training for staff across the NT Health system and advocated for system-wide critical reflection and transformation. The National Safety and Quality Health Service Standards 2 (Partnering with Consumers) and 6 (Communicating for Safety) ( 9 ) both require effective, coordinated and safe communication with diverse patients, carers, families and consumers. However, systems-wide policy implementation remains challenging in resource-stretched environments where audits focus on clinical diligence and clinical outcomes must also be prioritised. Participants reported feelings of powerlessness to change hospital culture and systems and identified many structural and systemic barriers to cultural safety, for example those related to time, space, staffing, language use, resources, policies, organisational values and priorities. Learning Health System (LHS) research may offer paths forward for addressing racism and unequal power at organisational levels and reducing disparities in population healthcare experiences. Staff feelings of powerlessness may be addressed by drawing on LHS models which engage in the social, collaborative work of change, recognise the effects of organisational cultures and structures on healthcare delivery ( 59 ), and hold equity as a “unifying objective” (53, p7). LHSs can accelerate the translation of research into practice ( 49 , 60 ) and “improve outcomes and quality of life for patients” (59, p5), thereby offering opportunities for all those working in the system to make a difference to transforming healthcare. To optimise the operation of a LHS, dynamic cycles of continuous leaning and improvement must be undertaken at the micro, meso and macro levels ( 54 ). In alignment with multi-level LHSs, participants in our study described training outcomes in individual, departmental, and hospital systems spheres. In our study, the microsystem level of learning and change ( 53 , 54 ) includes participant reports of personal transformation and clinical practice change to improve cultural safety. Encouragingly, we found a strong theme of ‘realising I can make a difference’ amongst participants enacting change at this micro-level and some reported cumulative positive impacts on healthcare provision over time. Findings indicate that training developed healthcare provider confidence to act as critical allies ( 2 ) who were able to identify and address bias in their own behaviour as well as that of colleagues. The mesosystem level of influence in a complex health environment requires collaboration ( 54 ) and focuses on implementing evidence to change service delivery models ( 53 ). This meso-level of the LHS aligns with the changes that participants reported across the culture and practice of whole departments. Findings indicate that the mode of training delivery, which facilitated discussion and joint action by colleagues with the support of team leaders, contributed to building a culture of meso-level change. Considering hospitals are often resistant to change ( 29 ), it is essential to have leaders who can act as change agents to successfully introduce and implement innovative practices ( 61 ). Consistent with previous research ( 45 ), our data indicates that senior clinicians are powerful champions for the creation of environments where cultural safety is expected and modelled. Their attendance endorsed the value of training and contributed to a safer workplace culture for junior staff to contribute and suggest changes at the departmental level. Other studies have also described the value of supporting champions who can “create tension for change” and extend the reach of implementation strategies (53, p7). The Communicate Study offers opportunities for critical allies to connect and learn together through a cultural safety champions group ( 11 ). The macrosystem level of the LHS framework ( 54 ) focuses on overall system performance and population health. Our study demonstrated that healthcare providers ‘feel powerless to make changes’ to cultural safety at this macro-level. However they recognised how much power the macro- has over the micro- and meso-levels. Adoption of evidence-based, culturally safe practices will require allocation of resources and close involvement of “quality improvement teams, project management, strategy, health informatics, and clinical program leaders” ( 53 , p.7). Further research is required to explore effective ways of engaging these key groups across NT hospital systems. Participants expressed concerns about a culture of systemic racism and constraints that hospital systems place on healthcare provider implementation of culturally safe practices. Findings suggest that macro-level changes to support culturally safe healthcare require broader action at policy and leadership levels, consistent with a LHS framework which “recognises that the goals pursued by an LHS cannot be achieved without adequate governance structures, policies, financing mechanisms and accountability measures” (54, p5). Participants in our study raised concerns that, compared to other performance indicators, cultural safety is not prioritised, monitored or measured adequately at the macro-level of healthcare systems. This finding is consistent with others who have advocated for objective, rigorous measurements of cultural safety in healthcare ( 2 ). Only patients can determine the cultural safety of their care ( 4 ) and so consideration of whose voices are heard and centred in healthcare user data is pivotal to an equitable LHS ( 53 ). Culturally and linguistically congruent methods are required to gather authentic patient experience data from people who speak Australian First Nations languages; survey methods have been shown to be ineffective ( 34 , 62 ). Recent research in the NT has explored culturally congruent methods for collection and analysis of qualitative patient satisfaction data with speakers of Australian First Nations languages ( 63 ) and this is an area of ongoing research in NT hospitals. Limitations of this study include that it only reports on healthcare provider perspectives on the impacts of cultural safety training. Researchers also observed healthcare provider behaviour but observation numbers were limited due to participants declining, and hospital time and space constraints. As cultural safety can only be determined by the recipients of healthcare, further research needs to evaluate the impacts of training on experiences of First Nations peoples in NT hospitals. Qualitative data about lived experiences of people who experience inequities in healthcare should be collected using culturally and linguistically congruent methods ( 62 ) with consideration for issues of data sovereignty, data governance and control ( 53 ). First Nations voices in research provide guidance and leadership as we work towards culturally safe communication in healthcare. Yolŋu researchers (First Nations peoples from North-East Arnhem Land, NT, Australia) are prominent advocates for the bringing together of First Nations and White knowledge systems to learn from each other and collaborate respectfully ( 31 , 64 ). A participant in our previous research suggested a Yolŋu pathway for learning from each other, as a way to address miscommunication and co-create “a gold standard” in healthcare where Indigenous and non-Indigenous partners “can be together on the same level” (31, p7). The current study demonstrates that a training program, co-designed and co-delivered by First Nations and White facilitators, can stimulate healthcare provider critical reflection and support meaningful decolonising action. The challenge is to expand this collaborative transformation across healthcare systems and cultures. Abbreviations ATS+ Ask the Specialist Plus CRT Critical Race Theory LHS Learning Health System NT Northern Territory RDH Royal Darwin Hospital Declarations Ethics approval statement and consent to participate This study was approved by the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (HREC-22-4297) and the Research Governance Office, Northern Territory Department of Health (EFILE2022/13836). The study was conducted in accordance with the Declaration of Helsinki guidelines. Study participants gave written consent prior to participation. Consent for publication The need for participant consent to complete surveys was waived by the Ethics Committee in keeping with the 2023 Australian National Statement on Ethical Conduct in Human Research (survey forms were completed anonymously and deemed highly unlikely to cause distress to participants). All co-authors consented to publication. Availability of data and materials Data from the study are not publicly available due to ethical considerations. Data may be available from the corresponding author on reasonable request. Competing Interests The authors declare no competing interests. Funding This study was funded by the Australian National Health and Medical Research Council (Partnership Grant, GNT2008644) and the Medical Research Futures Fund (Rapid Applied Research Translation, RARUR000143). Author APR was supported by a National Health and Medical Research Council Investigator Grant (GNT 2025371). Author contributions VK, MH and APR designed the study. VK, TA and CC facilitated the training. Data collection and analysis was conducted by EA, TA, MS, MH, EJ and VK. Drafting of the manuscript was led by EA with contributions from VK, TA, MS and MH. All authors contributed to manuscript revisions. All authors read and approved the final manuscript. Acknowledgements The Communicate Study Partnership acknowledges those who contributed to the delivery of Ask the Specialist Plus training. We thank ATS+ training co-facilitators: Candice McKenzie, Rachel Dikul Baker, Dr Aunty Bilawara Lee, Stuart Yiwarr McGath and Rarrtjiwuy Melanie Herdman. We also thank the NT Aboriginal Interpreter Service and Aboriginal Support Services Unit which includes Royal Darwin Hospitals Aboriginal Liaison Officers and Communicating for Safety Interpreters. We appreciate their contribution of time and expertise. Thank you to the healthcare providers who participated this evaluation by sharing their experiences and reflections. 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The science of Learning Health Systems: Foundations for a new journal. Learn Health Syst. 2017;1(1):e10020. Patton MQ. Qualitative evaluation and research methods 2nd ed. Newbury Park, CA: Sage; 1990. Charmaz K. The power of constructivist grounded theory for critical inquiry. Qualitative Inquiry. 2016;23(1):34-45. Charmaz K. Constructing grounded theory. 2nd ed. London: Sage; 2014. Reid RJ, Wodchis WP, Kuluski K, Lee-Foon NK, Lavis JN, Rosella LC, et al. Actioning the Learning Health System: An applied framework for integrating research into health systems. SSM - Health Systems. 2024;2. Menear M, Blanchette MA, Demers-Payette O, Roy D. A framework for value-creating learning health systems. Health Res Policy Syst. 2019;17(1):79. McDermott DR. Can we educate out of racism? Med J Aust. 2012;197(1):15. López-Cuello J, Uitdewilligen S, Sambeth A. Triggers and conducive factors for reflection in university students: a focus group study. Reflective Practice. 2024;25(4):484-98. Erb TL, Loppie C. The cost of Indigenous cultural safety training: Examining facilitator burnout and the impacts on health and wellness. AlterNative: An International Journal of Indigenous Peoples. 2023;19(2):417-25. Kerrigan V. Batji-gum dilba (Good talk medicine): Improving culturally safe communication between doctors and Aboriginal patients in the Northern Territory of Australia [Doctoral thesis]. Darwin, NT: Menzies School of Health Research, Charles Darwin University; 2022. Vinson AH. Culture as infrastructure in learning health systems. Learn Health Syst. 2021;5(3):e10267. Easterling D, Perry AC, Woodside R, Patel T, Gesell SB. Clarifying the concept of a learning health system for healthcare delivery organizations: Implications from a qualitative analysis of the scientific literature. Learn Health Syst. 2022;6(2):e10287. Rogers EM. Diffusion of innovations. 5th ed. New York: Free Press; 2003. Lowell A, Jones Y, Aitken R, Baker RD, Lovell J, Togni S, et al. Why surveys are ‘very hard’: Exploring challenges and insights for collection of authentic patient experience information with speakers of Australian First Nations languages. Rural and Remote Health. 2024;24(2):8380. Sena S, Armstrong E. Culturally congruent processes for collecting patient stories from speakers of Aboriginal languages in Central Australia. First Nations Health Communication Symposium Stories that matter: Reflecting and collaborating for change; Darwin and Alice Springs2025. Armstrong E, Maypilama Ḻ, Bukulatjpi Y, Gapany D, Fasoli L, Ireland S, et al. Nhaltjan dhu ḻarrum ga dharaŋan dhuḏi-dhäwuw ŋunhi limurr dhu gumurrbunanhamirr ga waŋanhamirr, Yolŋu ga Balanda: How we come together to explore and understand intercultural communication through a Yolŋu (First Nations Australian) metaphor. AlterNative: An International Journal of Indigenous Peoples. 2023;19(2):334-44. Additional Declarations No competing interests reported. Supplementary Files InterviewGuide.doc Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 25 Dec, 2025 Reviewers agreed at journal 17 Dec, 2025 Reviewers agreed at journal 15 Dec, 2025 Reviewers invited by journal 15 Dec, 2025 Editor assigned by journal 08 Dec, 2025 Editor invited by journal 18 Nov, 2025 Submission checks completed at journal 18 Nov, 2025 First submitted to journal 18 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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12:27:57","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":186161,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7826786/v1/5abcbe9fbb9ef7081563b40c.html"},{"id":98755436,"identity":"2022f9d6-4216-41c7-8e53-9aa367df949f","added_by":"auto","created_at":"2025-12-22 09:27:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":36675,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSurvey responses from all training sessions\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7826786/v1/6ae1b62d14c504b1147ef962.png"},{"id":98780052,"identity":"972306f6-b1a5-4e1a-a22e-152b35137400","added_by":"auto","created_at":"2025-12-22 12:31:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":179242,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSpheres of influence of ATS+ on health provider critical reflection\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7826786/v1/874acd1ec8e71645dcc4ddff.png"},{"id":98797644,"identity":"f39b703c-8214-49de-8729-02444db7057d","added_by":"auto","created_at":"2025-12-22 13:39:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1281163,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7826786/v1/ef5c9b7c-94e2-4555-955e-45cafca98b5b.pdf"},{"id":98755437,"identity":"780cc8ca-f1c8-4fd7-a815-20978ba01909","added_by":"auto","created_at":"2025-12-22 09:27:48","extension":"doc","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":86016,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewGuide.doc","url":"https://assets-eu.researchsquare.com/files/rs-7826786/v1/7d82fd809162f8d2b73d0bfe.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"“You can do it in another way”: healthcare provider reflections on cultural safety training in Australia’s Northern Territory","fulltext":[{"header":"Background","content":"\u003cp\u003eCultural safety and effective communication are essential to equitable quality healthcare, yet these so called ‘soft skills’ have long been undervalued within health service delivery (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Culturally safe communication is not merely about language proficiency or respectful relationships between patients and providers - it is about creating healthcare services that do not disempower service users based on Indigeneity, gender, age, sexual orientation, ethnicity, socioeconomic status, disability or religious beliefs (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This requires a fundamental shift from viewing culturally safe communication as an individual skillset to recognising it as a systemic responsibility of the healthcare system.\u003c/p\u003e \u003cp\u003eOn the continent colonisers called Australia, culturally safe communication in healthcare is an expectation set by government departments, training organisations and regulation authorities (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The Australian Human Rights Commission states that to address racism in healthcare all health professionals must receive cultural safety training (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). For health services to be clinically safe, effective and contribute to achieving health equity for First Nations peoples, culturally safe communication must be prioritised and improved (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However a gap remains between policy and practice (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTeaching cultural safety is challenging and evidence for its impact is limited (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). A recent paper observes that healthcare providers and services must be culturally competent as well as being culturally safe (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). To be culturally competent, individuals or an organisation must recognise and respect that patients may have different worldviews to the hegemony and adapt behaviours and services to deliver equitable health outcomes for all (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Cultural safety “focuses on the analysis of how power and privilege are distributed (among professionals, patients and organisations)” (2, p7). The extent to which cultural safety is achieved is determined by patients but responsibility for critical reflection and change rests with providers and institutions (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). To create a culturally safe health service for First Nations peoples in colonised countries such as Australia, Aotearoa New Zealand and Canada, transformative decolonial action must be taken by healthcare providers to minimise the dominance of Whiteness in healthcare systems (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCultural safety requires critical reflection, which in turn builds critical consciousness (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Critical consciousness supports a respectful approach to communication that reduces stereotypical thinking which manifests as racism (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Critical reflection is an active process and can be transformative when it supports a shift from awareness to practice change; it entails deep examination of one’s worldviews and assumptions as well as a focus on how power is used to maintain or challenge systems at personal and institutional levels (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Methods for effectively teaching critical reflection are not well described in existing literature, although ‘counterstories’ from structurally marginalised peoples have been advocated by Critical Race Theorists as an effective strategy (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) and there is evidence of their transformative potential (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Australia, the shared history of Western medicine and colonisation contribute to First Nations peoples feeling unsafe and disrespected when seeking healthcare (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Patients report confusion, aggression from healthcare professionals, interpersonal and institutional racism, treatment without consent and pressure to abandon cultural protocols, resulting in high rates of unplanned discharge from hospital, inequitable treatment, poorer health outcomes, distress, and avoidable mortality (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConversely, when patients feel culturally safe, health outcomes are likely to improve, trust in health services grows and there is less demand on health services because there is a reduction in repeat presentations (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Benefits also flow to healthcare providers. Healthcare providers have expressed a desire for more training that supports the delivery of culturally safe care (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) which has been shown to increase professional satisfaction for non-First Nations staff (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and interpreters (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), thereby potentially reducing burnout and staff turnover (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThese issues are of great relevance in Australia’s Northern Territory (NT) where most healthcare users identify as First Nations but the majority of healthcare providers are not. At the 360 bed Royal Darwin Hospital (RDH), the NT’s largest hospital located on unceded Larrakia country, approximately 70% of patients and 7.8% of staff identify as First Nations (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). The NT is linguistically and culturally diverse with approximately 100 Aboriginal languages and dialects (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). 58.5% of NT First Nations peoples speak an Aboriginal or Torres Strait Islander language at home (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). The NT has a high proportion of short-term healthcare staff from interstate or overseas, many of whom are unprepared for the complex medical environment of the NT, have limited knowledge of the unique richness and diversity of First Nations cultures, and – primed by stereotypes and negative perceptions of First Nations peoples – may experience culture shock and a sense of hopelessness while struggling to provide care that is culturally safe (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Communicate Study Partnership (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), which includes First Nations health professionals and community leaders and non-Indigenous health and communication practitioner-researchers, developed a locally designed, culturally safe communication training program called Ask the Specialist Plus (ATS+). When the training was conceptualised and delivered, there was no other cultural safety training offered to NT health staff beyond this project. ATS + consists of two components. The first is a podcast of seven 18-minute episodes titled \u003cem\u003eAsk the Specialist: Larrakia, Tiwi and Yolŋu stories to inspire better healthcare\u003c/em\u003e (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). The podcasts are based on the Freirean concept of ‘problem-posing education’ (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) and the Critical Race Theory concept of ‘counterstories’ (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), with doctors articulating questions which are then presented to the First Nations Specialists to provide their perspectives (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Doctors reported attitudinal and behavioural changes, inspired by critical reflection, after listening to the podcasts (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). The ‘plus’ of ATS + refers to weekly training sessions to encourage healthcare providers to engage in critical reflection, with groups co-facilitated by First Nations and White facilitators. This approach encourages dialogue, elevates marginalised voices, and recognises that the descendants of both coloniser and colonised share responsibility to dismantle racism (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 2021, ATS + was piloted at two RDH departments and evaluated through anonymous surveys (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Participants reported impacts on thinking, knowledge and behaviour; 90% of participants were satisfied. However the evaluation was limited because surveys lack the nuance and depth that can be found in qualitative data (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Considering the aim of the training was to enhance healthcare providers capacity to critically reflect, further research was needed. Subsequently, in 2023, The Communicate Study Partnership was contracted by NT Health to deliver ATS + to a larger cohort across the Top End. This paper reports on a qualitative evaluation of healthcare provider perspectives of the expanded ATS + program.\u003c/p\u003e\n\u003ch3\u003eTerminology\u003c/h3\u003e\n\u003cp\u003eIn this study, First Nations is a collective term used for the sovereign first peoples of the place now called Australia, inclusive of diverse nations of Aboriginal and Torres Strait Islander peoples. Throughout the paper, the word White has been used to refer to people who do not identify as First Nations. This word has been used by researchers to describe themselves and also by participants who learnt about Whiteness in the training. In this context, White helps to “counter the invisibility of race within the dominant population that is implicit in terms such as ‘non-Indigenous’” (47, p369). Bargaille (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) defined Whiteness in Australia “as a system of power relations that privileges non-Indigenous peoples over Indigenous Australian peoples” (47, p19). In Australia, White refers to a social category beyond observable characteristics which describe individuals who, knowingly or unknowingly, participate in a racialised society that positions them as superior or White in comparison to First Nations peoples (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). In using this term in this manner, we also acknowledge that colonialised Australia is culturally and ethnically diverse, and that participation in White society in Australia does not preclude experiencing racism and discrimination. Finally, White is capitalised not to indicate dominance, but to show that this is a socially constructed racial category and to challenge the often-used approach of only attaching the concept of race to minorities.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e\n\n\n\n \u003cp\u003e \u003c/p\u003e \u003cp\u003e\u003c/p\u003e\n\n "},{"header":"Methods","content":"\u003ch2\u003eResearcher backgrounds\u003c/h2\u003e\u003cp\u003eEA is a White Australian intercultural communication researcher and a speech pathologist who works collaboratively with First Nations Australian researchers and communities. TA is an Alawa and Marra woman from Darwin, NT, and early career research assistant at Menzies School of Health Research with experience in community-based health programs. MH is a White Australian qualitative health researcher who has lived and worked in the NT for over 10 years. APR is a White global health researcher and infectious disease clinician at RDH. MS is a White Australian global health professional living and working on Larrakia land. EJ is a White Australian and has been working as a health care professional in the NT for over 15 years. CC is an Aboriginal man from Larrakia Country; his 20-year career spans frontline healthcare delivery to executive level positions developing policies. VK is a White intercultural health communication researcher and practitioner, and was the only White co-facilitator of ATS + discussion groups.\u003c/p\u003e\u003ch3\u003eStudy Design\u003c/h3\u003e\u003cp\u003eThe Communicate Study Partnership (ClinicalTrials.gov ID NCT05629416) was developed to support the delivery of culturally safe healthcare in the NT(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The study is grounded in constructivist concepts of cultural safety (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), Critical Race Theory (CRT) (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) and Freirean pedagogy (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). An underpinning principle is the need to redress power imbalances between non-First Nations healthcare providers and First Nations peoples in hospital. The implementation research aims to stimulate critical consciousness among healthcare providers through dialogue which centres the voices of First Nations peoples. Intercultural communication training for healthcare providers has been developed as one way to address inequitable power dynamics that can manifest in clinical encounters (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). By equipping healthcare providers with skills to communicate more effectively across cultures - particularly in ways that acknowledge ongoing colonial impacts - intercultural communication training offers a practical approach to improving relationships, building trust, and delivering more equitable, person-centred care. Consistent with a Learning Health System framework (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e) the aim of the overall research program is to generate new knowledge about culturally safe communication training and its impact on staff, to enable learning which can be operationalised across NT hospitals.\u003c/p\u003e\u003ch3\u003eTraining design\u003c/h3\u003e\u003cp\u003eThe ATS + training consisted of 8 x one-hour sessions delivered weekly over eight-weeks to specific RDH departments. Training was designed for face-to-face delivery with an online option for those unable to attend in-person. Sessions were rostered to suit department teaching time. Each week focused on a specific topic (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), reflecting the 7 podcast episodes and an introductory module on cultural safety. Additional details about training design and delivery have been published previously (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eATS + session topics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTopic\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCultural safety introduction\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGet to know your patient\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunicating with your patient\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunicating with interpreters and your patient\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient-centred care\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInformed consent\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecognising and addressing racism\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerspectives on health and well-being\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003ch3\u003eData collection and sampling\u003c/h3\u003e\u003cp\u003eA mixed methods approach was planned comprising post-session participant surveys, pre and post training program interviews, and participant observations. All participants were asked to anonymously complete paper based or electronic surveys (accessed via a QR code) at the end of each session, as we have used previously (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Participants rated sessions across five domains using a 5-point Likert scale: content relevance to their work; the extent to which the session prompted reflections on attitudes; planned behaviour change; perception of facilitators; and attitudes towards session duration. Free text responses could be included.\u003c/p\u003e\u003cp\u003eParticipants were also invited to engage in semi-structured interviews either in-person or online with EA, TA, MH or EJ prior to the training and 3–6 months after completion (Interview guide: see Supplementary material 1). Staff from participating departments were purposefully sampled (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) to ensure a diversity in professions, length of experience in the NT and seniority. In pre-training interviews participants discussed their: personal and professional culture; experiences of working with patients who identify as First Nations; reflections on hospital culture and systems; approaches to communicating with patients; understanding of cultural safety and their roles in it. In post-training interviews guiding topics included: feedback about the training content, format, duration, delivery and facilitation; reflections about how participants felt post-training; stories about if and how ATS + had influenced their interactions at work; facilitators and barriers to implementation of what they had learnt through the training; what participants plan to do next. Participants were encouraged to raise additional relevant topics. Interviews were conducted in English, audio recorded and transcribed.\u003c/p\u003e\u003cp\u003eParticipants were also asked if they would agree to being observed at work before or after interviews, with the consent of health service users. A form was developed to record observations about culturally safe practice.\u003c/p\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eConstructivist grounded theory was used to facilitate critical inquiry (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). This is consistent with the aims of the Communicate Study’s transformative paradigm and aligns with principles of CRT. Interview transcriptions were inductively coded line-by-line by EA, TA and MH using gerunds (“-ing” words) to explicate processes of transformation (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Codes were then grouped into categories. Observational data was analysed by MH.\u003c/p\u003e\u003cp\u003eElectronic quantitative survey results were downloaded from \u003cem\u003eSurveyMonkey\u003c/em\u003e in a \u003cem\u003eMicrosoft Excel\u003c/em\u003e spreadsheet and paper surveys were scanned then entered into the same spreadsheet, organised by training week and department. MS then generated descriptive statistics for each question by calculating the proportion of responses corresponding to each score (1 to 5) and averaging these proportions across all weeks within each department. Free-text responses were collated into a Word document each week, keeping responses connected to participants’ professions but not otherwise identifiable. Free text responses were categorised by TA and reviewed by EA.\u003c/p\u003e\u003cp\u003eCo-authors EA, TA and MH met regularly to compare codes, identify commonalities, and iteratively develop themes. As themes were generated, the team developed a conceptual map to locate and analyse the impact of the ATS + program at different operational levels: personal and interpersonal, departmental, and hospital/systems level. This aligns with a Learning Health System framework which recognises that for a health system to effectively apply research findings, changes must be implemented at the micro, meso and macro levels (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Findings were further refined through discussions between EA, TA, MS and VK. All authors were involved in iterative rounds of paper drafting and feedback.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTraining was delivered between January and August 2023 and data was collected between November 2022 and November 2023. A total of 192 healthcare professionals from 8 departments based at RDH, Palmerston Regional Hospital and Gove District Hospital attended at least one session of ATS+ (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). 337 surveys were collected immediately following training sessions. Thirty interviews were conducted, 15 pre-training and 15 post-training. Twenty-one different healthcare providers participated in interviews, with nine available to complete both pre- and post-training interviews. Five staff were observed; data supported participant interviews but did not reveal new or different insights. Data was collected from doctors, nurses, clinical managers, allied health professionals (including pharmacists, physiotherapists, occupational therapists, speech pathologists), medical imaging professionals and medical students. Quotes are attributed by professional group and seniority but specific details on role and work locations have been omitted to protect identities.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipants and attendance at training\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCohort\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDates\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSessions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal enrolled\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAttendees per session** (mean)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIn person attendees (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAllied Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJanuary 2023 \u0026ndash; March 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot collected\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal, Infectious Diseases, Endocrinology, Nuclear Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFebruary 2023 \u0026ndash; March 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e73%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaediatrics, Obstetrics \u0026amp; Gynaecology, DonateLife*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJune 2023 \u0026ndash; August 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e53%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Organ and donor tissue coordination unit\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e**in person and online\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*** Weeks 2 and 3 were combined due to departmental requirements.\u003c/p\u003e \u003cp\u003e Over 90% of participants agreed or strongly agreed the training discussions were relevant to their work, that sessions prompted reflection on attitudes and that the facilitator styles were engaging and supportive. Similar proportions agreed that they planned to change their approach to working with patients and families, and that the duration of the discussion was perfect. Least agreement was found in relation to duration of sessions (45% strongly agree, 45% agree; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Some participants said the one-hour sessions were practical in their work day, others suggested that longer sessions would be more valuable and many requested more or ongoing training and support as they implemented what they had learnt. Some struggled to attend face-to-face training regularly due to constraints of a busy work environment but appreciated being able to engage with the ideas by listening to the podcast at a convenient time.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eDeveloping critical reflection and prompting change\u003c/h3\u003e\n\u003cp\u003e Participants used gerunds to describe the active processes they experienced which resulted in shifting from awareness to practice change. Participants reported change across four nested spheres of influence (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e): personal transformation, practice change, departmental culture, and hospital culture and systems. The arrows in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e represent two themes that cut across these four spheres. The theme of \u0026lsquo;realising I can make a difference\u0026rsquo; was strongest in relation to personal transformation and weakened as individuals identified departmental and hospital culture and systems as barriers. Reciprocally, \u0026lsquo;feeling powerless to make changes\u0026rsquo; was weakest in relation to personal transformation and increased in relation to departmental and hospital culture and systems. Gerunds were centred in data analysis and are used to present the results (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and below subheadings).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePersonal transformation: acknowledging, considering, reflecting, confronting, becoming aware\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eAcknowledging\u003c/strong\u003e \u003cp\u003ePre-training, many acknowledged the importance of cultural safety. This was evidenced through their commitment to attend the voluntary training program and demonstrated in their willingness to critically reflect. An allied health provider said when they started work they received an orientation booklet for the region, and asked some colleagues questions about culturally appropriate behaviour, however they still felt unprepared to support patients which motivated training attendance\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\u0026ldquo;Because I\u0026rsquo;m incompetent at the moment. Honestly, I\u0026rsquo;ve never worked in this area before, in this location and with these population groups. So I haven\u0026rsquo;t had any experience before, so I definitely need to try and upskill.\u0026rdquo; (Allied health provider, pre-training interview)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eParticipants with varying degrees of professional experience said the training stimulated their desire for personal transformation and reported that ATS\u0026thinsp;+\u0026thinsp;allowed them to critically reflect on what they don\u0026rsquo;t know. More experienced healthcare providers reflected on the impact of the training, describing a shift in perspective and desire to change practice that came from engaging with the podcast and group discussions:\u003c/p\u003e \u003cp\u003e\u0026ldquo;I thought I had a really good knowledge with our client group, but\u0026hellip; it wasn\u0026rsquo;t until I started really listening to the podcasts and coming to the group that I actually thought, \u0026lsquo;Oh, my gosh, there\u0026rsquo;s so many things I could improve on\u0026rsquo;. And I think each week there was always usually some kind of take-home message, \u0026lsquo;go and try this out.\u0026rsquo;\u0026rdquo; (Team leader, Allied Health, post-training)\u003c/p\u003e \u003cp\u003e Many participants acknowledged that the facilitators\u0026rsquo; communication styles helped to prompt critical reflection. In the week 7 survey, a medical student described the training as \u0026ldquo;very stimulating and at times too thought provoking but overall it is helping me reflect\u0026rdquo;. Participants found sessions particularly useful and engaging when First Nations facilitators shared their lived experiences. For example when Aboriginal Liaison Officers and Aboriginal Language Interpreters discussed their work in Week 4, one survey respondent wrote: \u0026ldquo;Could have listened to interpreters all day. Very glad it was pretty much all listening to them and the discussion. Very very helpful.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cem\u003eConsidering\u003c/em\u003e: Before ATS+, participants from dominant cultural backgrounds were commonly taken-aback when asked to consider their own personal and professional cultures and roles in the healthcare system. A senior nurse said: \u0026ldquo;I am as boring as they come. I think my grandparent\u0026rsquo;s grandparents were convicts\u0026hellip; I\u0026rsquo;m very pale.\u0026rdquo; After ATS+, most reported growing awareness of how their own culture can impact patient interactions. This was particularly poignant for participants who belonged to the dominant colonising culture. After completing the training, one allied health provider realised: \u0026ldquo;I\u0026rsquo;ve been brought up in a White world with White institutions. \u0026hellip; Until they [facilitators] said that, I\u0026rsquo;d never even considered it.\u0026rdquo;\u003c/p\u003e \u003cp\u003eIn a pre-training interview, a doctor considered the dominance of Whiteness in healthcare and expressed concerns that matched the training content:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;This year was probably the first time I\u0026rsquo;ve really held up a mirror to what am I bringing to this interaction?\u0026hellip; It was almost like cultural whiplash\u0026hellip; The mirror that I held up to myself was that our public healthcare system is built for White health focussed populations, it\u0026rsquo;s like, unfortunately, a deeply racist framework of care. \u0026hellip; And it\u0026rsquo;s hard day-to-day to operate in that, knowing that\u0026hellip; the fundamental way we deliver healthcare is based on our set of priorities and not theirs.\u0026rdquo; (Doctor, pre-training interview)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eReflecting\u003c/em\u003e: The training encouraged participants to reflect on, and discuss, the often-unacknowledged power dynamics between patients and providers. A senior doctor wrote in the week 1 survey: \u0026ldquo;Understanding the complexity \u0026amp; power-imbalance where I work is necessary to have an impactful therapeutic relationship.\u0026rdquo; For one senior nurse, it was \u0026ldquo;a punch in the guts\u0026rdquo; when they realised that, due to their personal and professional background, they have capacity to exert power over patients which can contribute to inequitable healthcare delivery:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Personal reflection of my own power imbalance was a bit of a punch in the guts kind of feeling\u0026hellip; I\u0026rsquo;d never considered myself to be anyone in a position of power within the workplace\u0026hellip; it was a different way to think about cultural safety that I think was really good. \u0026hellip;you\u0026rsquo;re not just trying to learn stuff but actually trying to think through the implications about that existing power imbalance.\u0026rdquo; (Senior Nurse, post-training interview)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSeveral participants reflected that the training helped them identify that their teams were already practicing culturally safe person-centred care including conducting holistic assessments, advocating for patient priorities, and using interpreters to ensure patients were informed about treatment before consenting or declining. These reflections made them proud and gave team leaders a chance to encourage staff to continue with the positive work.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConfronting\u003c/strong\u003e \u003cp\u003eSome said the training was confronting and made them feel uncomfortable. This occurred particularly in the first weeks when complex concepts including Whiteness and racism were discussed.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\u0026ldquo;There was this moment that I thought was really powerful. Vicki [one of the White facilitators], this is in the first week, she asked people to describe their culture\u0026hellip; and people couldn't do it. It was that idea that if you're a white person you don't have a culture because we're the norm. So\u0026hellip; there was an awkward silence in the room and then she put a slide up that talked about Whiteness and White culture. I know, I think, a lot of people were confronted by that. But, what an important discussion to have!\u0026rdquo; (Team leader, Allied health, post-training interview)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eSome participants also felt uncomfortable when asked to consider that all White people are \u0026ldquo;foreigners\u0026rdquo; living on unceded lands of First Nations people. This idea was shared by Tiwi Elder Pirrawayingi Puruntatameri in the podcast and repeated by facilitators. For those who continued attending, this discomfort shifted over the sessions, for example in week 1 a participant wrote in a survey that they felt \u0026ldquo;a lot of blame\u0026rdquo; particularly from the White facilitator but in week 2 someone from the same team wrote: \u0026ldquo;This felt better than last week - didn\u0026rsquo;t feel as pointed at us as the problem but part of the solution.\u0026rdquo; (Medical imaging professional, week 2 survey)\u003c/p\u003e \u003cp\u003e The training supported participants to confront racism as both interpersonal and systemic. Some reflected deeply on their own roles in perpetuating or challenging racism. An Allied Health provider wrote in the week 7 survey: \u0026ldquo;I am getting better at self-reflection despite often feeling very uncomfortable at discovering my level of racism/bias/white privilege.\u0026rdquo; In a post-training interview, an allied health provider reflected on the commonly held misbelief among colleagues that racism is predominantly overt acts of discrimination and hate:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I think it's the slow-moving recognition of what racism is and what racism might not be. And actually that was a big thing for me to try and work out. Racism isn't just calling people racist things. It's our healthcare - there is so much racism everywhere. It doesn't actually have to be something offensively called, but some people still are stuck there and not open to change and it's sad.\u0026rdquo; (Allied health provider, post-training interview)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eBecoming aware\u003c/strong\u003e \u003cp\u003eParticipants became aware of the challenges faced by people from remote First Nations communities, especially the impacts of leaving home for healthcare. As they became aware of the reality of seeking healthcare for many of their patients, they changed their practice by working more with patients and families to shape rehabilitation goals and advocated for better discharge planning. Many became aware of the need to partner more with Aboriginal Liaison Officers, Aboriginal health professionals, interpreters, families and patients themselves. However, some recognised that there aren\u0026rsquo;t enough First Nations staff to meet needs.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\u0026ldquo;I know from Ask the Specialist [podcast] now we can't expect that this work just sits with Aboriginal people, but how can we do it hand in hand? It's very hard when we're a team of White people.\u0026rdquo; (Allied Health provider, post-training interview)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e As participants developed a deeper awareness of cultural protocols that shape communication within and between cultures, including the range of First Nations languages understood and spoken by patients and the complex demands placed on interpreters, they began to deepen their understanding of how intercultural communication challenges can impact patient outcomes. After the training, many were aware of how ineffective communication contributes to culturally unsafe outcomes such as patients missing appointments. Others began to recognise that White communication practices, such as asking a long list of questions, can contribute to culturally unsafe interactions. One participant recalled a difficult encounter with a patient that was confusing at the time but took on new meaning post-training:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Basically, they got really upset with me, just for asking... They got actually quite angry. But I hadn\u0026rsquo;t really said anything offensive, I think I had only prompted a question about \u0026lsquo;Hey, where do you get your medications from?\u0026rsquo; or \u0026lsquo;Did you bring any of your medicines in?\u0026rsquo;. Anyway, but this person got quite upset, called me a few things and pretty much pulled the blanket up over their head and that was the end of the interaction... (Now) I think what would\u0026rsquo;ve happened to that patient is I was probably the sixth person to walk through that morning and bother her with questions about things.\u0026rdquo; (Allied health provider, post-training interview)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePractice change: unpacking, interacting, building\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eUnpacking\u003c/strong\u003e \u003cp\u003e Participants shared positive stories of individual practice change as they unpacked what they\u0026rsquo;d learnt, reflected on their roles and realised they could make a difference to patient experiences. Many began to unpack the facilitator\u0026rsquo;s suggestion that dehumanising language used in healthcare - such as \u0026ldquo;compliant\u0026rdquo; and \u0026ldquo;non-compliant\u0026rdquo; which can imply the patient is the problem \u0026ndash; should be changed. One participant highlighted how deeply embedded such language is, acknowledging the challenge of finding alternative ways to communicate about patients in fast-paced work environments.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;Some of the language we use around patients and labelling people as compliant, non-compliant, non-adherent, stuff like that, it is very difficult to explain a situation without using a word like that\u0026hellip; in a really quick way, without saying one of those words \u0026hellip; sometimes I would sit there [in the training] being like, \u0026lsquo;well we can't do it any other way\u0026rsquo;. (But) You can. You have to take more time to do it, you can do it in another way. But I think it takes you to talk through in front of other people and your peers \u0026hellip; Because you actually end up having to say things out loud and practice what you preach.\u0026rdquo; (Allied health provider, post-training interview)\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInteracting\u003c/strong\u003e \u003cp\u003e The training supported participants to change how they interact with patients. Before the training, there was wide variation in participants\u0026rsquo; awareness of First Nations languages and of potential impacts of linguistic diversity on healthcare interactions. When asked if they could name any First Nations languages, one participant had difficulty pronouncing the three languages they could name and said\u003c/p\u003e \u003c/p\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I\u0026rsquo;m not going to go any further\u0026hellip; I mean I know places fairly well, because I like maps so I do look at maps. But I\u0026rsquo;ve never been the person to request an interpreter. And I feel as though I don\u0026rsquo;t usually ask people what language because either it\u0026rsquo;s written down or \u0026ndash; you know, it\u0026rsquo;s not something I think to ask somebody, so I would not be confident.\u0026rdquo; (Senior nurse, pre-training interview)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePre-training observational data indicated a lack of involvement of interpreters in patient-provider interactions. After the training, many participants reported changing their approach. This included checking the patient\u0026rsquo;s language, accessing interpreters, and being more confident with booking an interpreter. A doctor reflected that they had not appreciated the crucial role of interpreters until the training. They described having their \u0026ldquo;mind blown on several occasions\u0026rdquo; when they thought they were communicating reasonably well in English but then, the extent of miscommunication was revealed when an interpreter was involved. After completing the training, an Allied Health provider said they advocated for a patient to access an interpreter, despite resistance from a colleague, and saw positive outcomes as a result:\u003c/p\u003e \u003cp\u003e\u0026ldquo;I went to do some discharge counselling and\u0026hellip; I was like [to a nurse], \u0026lsquo;Oh, I want to organise an interpreter for this discharge.\u0026rsquo; The nurse had been like, \u0026lsquo;Oh no, he speaks fine. Don't stress about that.\u0026rsquo; But then I was like, \u0026lsquo;Oh no, I think if someone's documented it, it's probably worthwhile following through.\u0026rsquo; So I still organised it and it was good because \u0026hellip; when I went in, we talked about the medicines and I don't speak any language, but I could kind of tell that she [the interpreter] was expanding into, when she was talking about the heart, she was using lots of really cool analogies, which I wasn't really thinking - I had never thought about before.\u0026rdquo; (Allied health provider, post-training interview)\u003c/p\u003e \u003cp\u003e Participants discussed changing their communication styles to be more culturally congruent with patients. They discussed using multimodal communication strategies (e.g. images, models, analogies) to make information more accessible. Participants applied these strategies across all stages of patient journeys, from taking a case history to discharge or end of life planning. One participant recounted a meeting with a patient from a remote community and their family to discuss the patient\u0026rsquo;s end of life plan. The participant implemented what they learned: they consulted an interpreter before the family meeting to get advice on how best to conduct the meeting and the interpreter suggested using drawings and models to enhance communication and allow the family time to consider what was being explained. The clinician felt these changes improved the interaction:\u003c/p\u003e \u003cp\u003e\u0026ldquo;(I) just really explained everything in a really careful way with lots of pauses, lots of space for silence\u0026hellip; and really expressed my sorrow. It just felt like a really positive experience, which is a horrible thing to say when it\u0026rsquo;s someone\u0026rsquo;s death, but it just felt really compassionate, considered and respectful and the family really seems to appreciate it too.\u0026rdquo; (Doctor, post-training interview)\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eBuilding\u003c/strong\u003e \u003cp\u003e Over the course of the training, some participants described building confidence to implement small but impactful new strategies and increased work satisfaction when they observed positive patient responses. An allied health professional said they \u0026ldquo;felt almost embarrassed\u0026rdquo; about some previous patient interactions after they saw the difference it could make to change one or two things within their control. A nurse had a similar realisation regarding the cumulative impact of making small changes over time\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\u0026ldquo;If you make an effort [to learn about communicating], someone else will make an effort back. It doesn't have to bridge the whole lot, but it just has to be little tiny steps, and then eventually you go, hey, look what we've done in six months! Like, looking back, now we've actually achieved a lot I think.\u0026rdquo; (Senior nurse, post-training interview)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e The training session on building rapport with patients was particularly valued by participants who implemented strategies learned. When introducing themselves to patients, some participants started to share personal details about their own lives, for example using maps on their mobile phone to show patients where they come from. Others developed rapport by trying to \u0026ldquo;find common ground first\u0026rdquo;, for example, finding people they know in common. While these practices sometimes felt strange to participants who had been taught to maintain a professional distance in the White healthcare system, many were willing to try, and subsequently built their confidence with the new practices and began sharing the ideas with colleagues. One participant said the training provided them with an understanding of why some interactions \u0026ldquo;weren\u0026rsquo;t working\u0026rdquo; and strategies to use in these situations:\u003c/p\u003e \u003cp\u003e\u0026ldquo;it taught me that there are solutions, there are ways around it, so it's not just dismiss it and that's the end of that interaction with that patient... And the interactions are better and I do find it more rewarding as well, building rapport with patients\u0026hellip; It helped me provide better healthcare which ultimately is the reason I get up to do my work every day.\u0026rdquo; (Allied health provider, post-training interview)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDepartmental culture and practices: creating, rearranging, implementing, making time, supporting, committing\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eCreating\u003c/strong\u003e \u003cp\u003e Participants spoke about wanting to create a sense of shared purpose and direction in their departments that reflected the principles learnt through the training. Participants became increasingly aware of departmental cultures \u0026ndash; both the strengths and the challenges of changing practices. Some spoke about the benefits of completing the training with their team, which helped create an anti-racist culture and generated staff support for implementing changes across their department.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\u0026ldquo;if you know that a lot of people have had this training, you maybe are able to have trust in your colleagues... I feel like it probably gets a little bit political in a sense, but knowing that, I think it would be good to know that everyone's had the opportunity to consider those things.\u0026rdquo; (Allied Health provider, post\u0026ndash;training interview)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRearranging and implementing\u003c/strong\u003e \u003cp\u003eBefore training, researchers observed that hospitals were not well set up to be supportive of culturally safe interactions. After training, participants began rearranging spaces and improving departmental processes. Some spoke about changing outpatient clinic set-ups \u0026ldquo;to be more patient focussed\u0026rdquo;. Others created meeting spaces outside the cold hospital building so that patients might feel more comfortable. First Nations art was displayed to make clinical spaces more welcoming in some departments and others worked on implementing changes to support the building of rapport. In one department, landscape photos taken by staff when travelling through the NT were framed and hung with information about each staff member as a way of sharing personal stories from staff and to display Country.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eAnother department arranged mutual learning sessions between healthcare providers and interpreters as an initiative to improve culturally safe communication. These sessions led to changes in the way clinical procedures were explained, for example changing specific words with dual meanings that could be misinterpreted such as dye / die.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMaking time\u003c/strong\u003e \u003cp\u003eDuring observational data collection, the systemic pressures that restrict providers from making time to practice culturally safe communication were documented. A senior nurse spoke about time pressures to move quickly, and conversely, the rewards of making time which allowed for embracing silence in clinical encounters, highlighting its significance in culturally safe communication\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\u0026ldquo;Look, you don't have time to allow it, and I can tell you, there are so many reasons that it's hard to have that silence. But once you've found the skill to be able to sit in the silence comfortably in yourself, you actually get way more out of the patient.\u0026rdquo; (Senior Nurse, pre-training interview)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eAfter completing the training, another senior nurse spoke about how they learnt to work quickly because that was hospital culture: \u0026ldquo;just always be pushing \u0026ndash; being productive\u0026rdquo;. However they observed that the pressure to be efficient was sometimes \u0026ldquo;self-imposed\u0026rdquo;, acknowledging that they work in a smaller department and therefore may have autonomy to change how they work:\u003c/p\u003e \u003cp\u003e\u0026ldquo;So I probably have more power to change some of that than other people who work in bigger departments do\u0026hellip; We\u0026rsquo;re constantly expecting more and more of staff\u0026hellip; but maybe expecting less of staff would mean that people had a bit more time for patients.\u0026rdquo; (Senior nurse, post-training interview)\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSupporting and committing\u003c/strong\u003e \u003cp\u003eThe support of departmental leaders was appreciated by participants, both in terms of \u0026ldquo;being taken off the floor\u0026rdquo; to attend training and committing to changes to improve cultural safety across a department. Training attendance by senior staff also demonstrated their prioritisation of cultural safety.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\u0026ldquo;(I said to my team) we have the training at 8.30 so you\u0026rsquo;ll be starting then\u0026hellip;I think they knew I wasn\u0026rsquo;t budging on it and that I had support from the [department head] that this was our priority. \u0026hellip; then they turned up and we would chat about it afterwards and it was very positively received and I can see their change in practice has been really positive.\u0026rdquo; (Team Leader, post-training)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eSome participants highlighted systemic barriers to participation in ATS\u0026thinsp;+\u0026thinsp;due to the program being non-compulsory and run during their lunch break. Systems pressure and the lack of support from some managers led to some participants dropping out:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I think with attendance dropping off, some of that for people was just pressure from their work area to cover the wards\u0026hellip; we\u0026rsquo;re always going to be busy and it's an hour [once a week for 8 weeks]\u0026hellip; being busy, it's often been used as a reason not to engage more in-depth with this sort of learning.\u0026rdquo; (Team leader, post-training interview)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eHospital systems and culture: realising, constraining, feeling powerless, doubting, taking responsibility, continuing\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eRealising\u003c/strong\u003e \u003cp\u003eParticipants realised how White Australian hospitals are and developed more nuanced understandings of the systemic factors affecting First Nations peoples' experiences of healthcare.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\u0026ldquo;ATS\u0026thinsp;+\u0026thinsp;taught us to think about it in a way where you can go \u0026lsquo;Oooh wait. You know, it\u0026rsquo;s not me specifically and I shouldn\u0026rsquo;t take offence to that.\u0026rsquo; But it\u0026rsquo;s all of these things that are impacting them [First Nations peoples] when they come into a hospital service that\u0026rsquo;s pretty much set up for any white culture to come in and get all the benefits and treated well. But anyone who\u0026rsquo;s outside of that scope, it\u0026rsquo;s quite challenging to navigate.\u0026rdquo; (Allied health provider, post-training interview)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eOne senior nurse raised concerns that racism and a lack of healthcare provider communication skills created a \u0026ldquo;double standard\u0026rdquo; of healthcare across the system:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I do think that the colour of your skin, the language that you speak and where you come from does have an impact on your health outcomes. Which is really sad\u0026hellip; We aim to provide good care for everyone. I don't think it's intentional a lot of the time, but I do think it's a double standard.\u0026rdquo; (Senior Nurse and Team Leader, pre-training interview)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants realised the heavy demands that the First Nations workforce carries working in a White healthcare system:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;[My colleague] just made me realise \u0026hellip; the culture of our organisation. \u0026hellip; How White all our systems were. And just as an Aboriginal person in a predominantly White work unit, just how isolating, how hard that can be.\u0026rdquo; (Team Leader, Allied health, post-training interview)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConstraining and feeling powerless\u003c/strong\u003e \u003cp\u003e Post-training, participants discussed how hospital cultures and systems constrain their ability, and sense of power, to sustainably implement culturally safe practices. While a few participants in senior medical positions felt they had some influence over systemic issues, junior staff reported feeling particularly constrained and frustrated. One leader said that \u0026ldquo;the hospital is just so big\u0026rdquo; and when asked about large-scale changes to create environments that are more comfortable for First Nations peoples, said \u0026ldquo;I don\u0026rsquo;t know how they can change that.\u0026rdquo;\u003c/p\u003e \u003c/p\u003e \u003cp\u003eMany reported that cultural safety is not prioritised in healthcare systems. Evidence for this included lack of measuring or monitoring quality of intercultural communication, particularly compared to other performance indicators:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;There\u0026rsquo;s no audits on it. There\u0026rsquo;s no KPIs on it. The hospital audits all the paperwork, they audit your notes, they audit forms, they audit your charts, and you get feedback and you have to meet targets, like hand hygiene and all of that\u0026hellip; (but) it\u0026rsquo;s not on the radar for reporting how good you are at communicating with your patients.\u0026rdquo; (Doctor, post-training interview)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTime and understaffing were frequently-mentioned constraints that left participants feeling powerless to influence systems or create change. One participant reported that understaffing requires her to take responsibility for systemic and administrative issues, limiting her opportunities to build relationships with patients:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;We are usually understaffed, comparative to the amount of patients there are. So, we're usually dealing with backend problems\u0026hellip; most of the time that kind of ends up trumping us to be able to just sit down with patients and talk.\u0026rdquo; (Allied health provider, post-training interview)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDoubting\u003c/strong\u003e \u003cp\u003eMany expressed doubt about how much impact the training could realistically have within a racist system. One doctor acknowledged that while the training had a positive influence, their ability to apply lessons learned was constrained by structural issues such as chronic hospital pressures and internal emergencies, limiting time and space for culturally safe care. This doubt was particularly strong when participants considered the difficulties of addressing inherent power imbalances between patients and providers\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\u0026ldquo;I don\u0026rsquo;t know how you necessarily get away from that [power imbalance] in a hospital setting. I feel like it\u0026rsquo;s not an environment that\u0026rsquo;s conducive to being really much else.\u0026rdquo; (Senior nurse, pre-training interview)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eA junior doctor doubted the capacity of senior staff to lead change and instead said that changing culturally unsafe systems would need to be addressed by their own generation of staff as they progress through the hierarchy:\u003c/p\u003e \u003cp\u003e\u0026ldquo;my experience of the racism that I\u0026rsquo;ve seen in my five months of being in the Territory has been generally coming from a generation above me, generally doctors who seem to place the burden of responsibility and the burden of fixing these systemic issues back onto First Nations people. I think myself and the younger cohort of doctors, nurses, allied health workers, have this attitude of politely, we\u0026rsquo;ve just, our dominant culture has just f#%*ed over the Indigenous people of our country. So, we should come from that very humble place and not expect them to pull themselves up single-handedly because we have done the damage.\u0026rdquo; (Junior doctor, pre-training interview)\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTaking responsibility and continuing\u003c/strong\u003e \u003cp\u003eParticipants recognised the need to take responsibility for change and continue to learn. Some suggested that it may be possible to change racism throughout healthcare if all people working within the system participated in training like ATS+, including university students, early career health professionals, experienced clinicians, leaders, administration staff, transport staff, cleaners and other professionals. Many thought ATS\u0026thinsp;+\u0026thinsp;would be a valuable addition to the extensive list of essential training. Some believed the training should be completed before new staff interact with patients, while others recognised the value of doing, or repeating, the training once staff were familiar with the work context and patient groups.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e\u0026ldquo;Compared to some of the essential training we do, it\u0026rsquo;s shocking that it [ATS+] isn\u0026rsquo;t considered essential training, and it\u0026rsquo;s really powerful training, because it affects you. I know it is confronting for some people, but it does affect your life. It\u0026rsquo;s not just clinical, it\u0026rsquo;s how you see yourself in the system, and it\u0026rsquo;s not just the hospital system, it\u0026rsquo;s like a societal system that\u0026rsquo;s oppressive. And I guess that part is confronting\u0026hellip; One of my favourite podcasts was around recognising privilege and structural racism, and using terms that a lot of White people find confronting, or invokes white fragility, but I\u0026rsquo;m at a point now where I think those lessons and those terminologies are very important to say and feel, and they\u0026rsquo;re powerful words, they\u0026rsquo;re important words.\u0026rdquo; (Senior Nurse, post-training interview)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eAn important insight for many participants was the realisation that becoming a culturally safe practitioner is an ongoing, often cyclical journey, not a competency with an endpoint that can then be \u0026lsquo;achieved\u0026rsquo;. Many requested repeated and ongoing access to the training to support cultural safety in the hospital:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I think White people do this a lot\u0026hellip; we go, \u0026lsquo;I\u0026rsquo;ve been to a cultural safety course, and I have listened to the \u003cem\u003eAsk the Specialist\u003c/em\u003e podcast, so I don\u0026rsquo;t need to do this anymore. I\u0026rsquo;m trained.\u0026rsquo; Like it\u0026rsquo;s a very White, Western, empirical medicine, you\u0026rsquo;ve done the training, you\u0026rsquo;re now competent, you don\u0026rsquo;t need to do it again. And I think that was the most powerful thing that came out of that for me, was like it never ends. We need to keep doing it\u0026hellip; Learning that I\u0026rsquo;m a White person, I work in a White system, like it\u0026rsquo;s very easy for me to do the training and then forget that training (because) I\u0026rsquo;m working in a system that doesn\u0026rsquo;t support improving communications with First Nations people. It doesn\u0026rsquo;t prioritise it.\u0026rdquo; (Senior Nurse, pre-training interview)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides detailed evidence of how Ask the Specialist Plus training developed participants\u0026rsquo; capacity to critically reflect on their power and privilege as healthcare providers working in NT hospitals, extending on previous evidence (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Importantly, through pre and post interview design, this study also provides evidence of participants implementing changes over time and practicing what they learned about improving the cultural safety of healthcare provided to First Nations people. Reflection and action are evidenced by the gerunds and phrases ATS\u0026thinsp;+\u0026thinsp;participants themselves used to describe training impacts: acknowledging, considering, reflecting, confronting, becoming aware, unpacking, interacting, building, creating, rearranging, implementing, making time, supporting, committing, realising, constraining, feeling powerless, doubting, taking responsibility and continuing. These outcomes of critical reflection and transformative action are central to overturning the dominance of Whiteness and decolonising healthcare systems (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis research fills an important gap in evidence for impacts of cultural safety training (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Previous cultural safety training programs have struggled to encourage critical reflection, for example because medical students describe themselves as concrete thinkers and expect to be offered a list of solutions (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Our findings indicate healthcare providers can be supported to challenge such expectations when training is designed to both encourage and confront participants. We found that a careful balance between challenging material and practical strategies can facilitate productive participant critical reflection on complex concepts such as Whiteness, racism and power dynamics. This finding aligns with studies which have found that a challenging, uncomfortable or confronting trigger can be conducive to critical reflection, particularly when disquiet is paired with a supportive context for guided interaction with peers and teachers (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipants in this study appreciated learning from the lived experiences of First Nations facilitators. However, we advocate that training should continue to be facilitated by First Nations and White facilitators working in partnership, recognising both the expertise of First Nations facilitators and the responsibilities of White partners to address systemic inequities. This collaborative approach reduces the risk of this work becoming an unmanageable, unwanted and uncompensated cultural and colonial load for First Nations staff (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Support for the health and wellbeing of facilitators undertaking this confronting work must also be prioritised (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study demonstrates the value of supporting staff to recognise that they have previously been educated in a White biomedical communication style and that they have the power to change their approaches to better align with patient communication norms. ATS\u0026thinsp;+\u0026thinsp;training provided participants with strategies for making these changes based on suggestions from First Nations participants in previous studies (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). Ongoing, meaningful, coordinated partnerships with those who have experienced healthcare inequity can support hospital staff to challenge the White systems which create and perpetuate inequity, mindful that equitable co-design requires significant time, strong relationships and specific skills (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsistent with past research (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), many participants suggested that ATS\u0026thinsp;+\u0026thinsp;should be mandatory and ongoing training for staff across the NT Health system and advocated for system-wide critical reflection and transformation. The National Safety and Quality Health Service Standards 2 (Partnering with Consumers) and 6 (Communicating for Safety) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) both require effective, coordinated and safe communication with diverse patients, carers, families and consumers. However, systems-wide policy implementation remains challenging in resource-stretched environments where audits focus on clinical diligence and clinical outcomes must also be prioritised. Participants reported feelings of powerlessness to change hospital culture and systems and identified many structural and systemic barriers to cultural safety, for example those related to time, space, staffing, language use, resources, policies, organisational values and priorities. Learning Health System (LHS) research may offer paths forward for addressing racism and unequal power at organisational levels and reducing disparities in population healthcare experiences.\u003c/p\u003e \u003cp\u003eStaff feelings of powerlessness may be addressed by drawing on LHS models which engage in the social, collaborative work of change, recognise the effects of organisational cultures and structures on healthcare delivery (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e), and hold equity as a \u0026ldquo;unifying objective\u0026rdquo; (53, p7). LHSs can accelerate the translation of research into practice (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e) and \u0026ldquo;improve outcomes and quality of life for patients\u0026rdquo; (59, p5), thereby offering opportunities for all those working in the system to make a difference to transforming healthcare. To optimise the operation of a LHS, dynamic cycles of continuous leaning and improvement must be undertaken at the micro, meso and macro levels (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). In alignment with multi-level LHSs, participants in our study described training outcomes in individual, departmental, and hospital systems spheres.\u003c/p\u003e \u003cp\u003eIn our study, the microsystem level of learning and change (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e) includes participant reports of personal transformation and clinical practice change to improve cultural safety. Encouragingly, we found a strong theme of \u0026lsquo;realising I can make a difference\u0026rsquo; amongst participants enacting change at this micro-level and some reported cumulative positive impacts on healthcare provision over time. Findings indicate that training developed healthcare provider confidence to act as critical allies (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) who were able to identify and address bias in their own behaviour as well as that of colleagues.\u003c/p\u003e \u003cp\u003eThe mesosystem level of influence in a complex health environment requires collaboration (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e) and focuses on implementing evidence to change service delivery models (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). This meso-level of the LHS aligns with the changes that participants reported across the culture and practice of whole departments. Findings indicate that the mode of training delivery, which facilitated discussion and joint action by colleagues with the support of team leaders, contributed to building a culture of meso-level change.\u003c/p\u003e \u003cp\u003eConsidering hospitals are often resistant to change (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), it is essential to have leaders who can act as change agents to successfully introduce and implement innovative practices (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). Consistent with previous research (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), our data indicates that senior clinicians are powerful champions for the creation of environments where cultural safety is expected and modelled. Their attendance endorsed the value of training and contributed to a safer workplace culture for junior staff to contribute and suggest changes at the departmental level. Other studies have also described the value of supporting champions who can \u0026ldquo;create tension for change\u0026rdquo; and extend the reach of implementation strategies (53, p7). The Communicate Study offers opportunities for critical allies to connect and learn together through a cultural safety champions group (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe macrosystem level of the LHS framework (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e) focuses on overall system performance and population health. Our study demonstrated that healthcare providers \u0026lsquo;feel powerless to make changes\u0026rsquo; to cultural safety at this macro-level. However they recognised how much power the macro- has over the micro- and meso-levels. Adoption of evidence-based, culturally safe practices will require allocation of resources and close involvement of \u0026ldquo;quality improvement teams, project management, strategy, health informatics, and clinical program leaders\u0026rdquo; (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, p.7). Further research is required to explore effective ways of engaging these key groups across NT hospital systems.\u003c/p\u003e \u003cp\u003eParticipants expressed concerns about a culture of systemic racism and constraints that hospital systems place on healthcare provider implementation of culturally safe practices. Findings suggest that macro-level changes to support culturally safe healthcare require broader action at policy and leadership levels, consistent with a LHS framework which \u0026ldquo;recognises that the goals pursued by an LHS cannot be achieved without adequate governance structures, policies, financing mechanisms and accountability measures\u0026rdquo; (54, p5). Participants in our study raised concerns that, compared to other performance indicators, cultural safety is not prioritised, monitored or measured adequately at the macro-level of healthcare systems. This finding is consistent with others who have advocated for objective, rigorous measurements of cultural safety in healthcare (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOnly patients can determine the cultural safety of their care (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and so consideration of whose voices are heard and centred in healthcare user data is pivotal to an equitable LHS (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Culturally and linguistically congruent methods are required to gather authentic patient experience data from people who speak Australian First Nations languages; survey methods have been shown to be ineffective (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e). Recent research in the NT has explored culturally congruent methods for collection and analysis of qualitative patient satisfaction data with speakers of Australian First Nations languages (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e) and this is an area of ongoing research in NT hospitals.\u003c/p\u003e \u003cp\u003eLimitations of this study include that it only reports on healthcare provider perspectives on the impacts of cultural safety training. Researchers also observed healthcare provider behaviour but observation numbers were limited due to participants declining, and hospital time and space constraints. As cultural safety can only be determined by the recipients of healthcare, further research needs to evaluate the impacts of training on experiences of First Nations peoples in NT hospitals. Qualitative data about lived experiences of people who experience inequities in healthcare should be collected using culturally and linguistically congruent methods (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e) with consideration for issues of data sovereignty, data governance and control (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFirst Nations voices in research provide guidance and leadership as we work towards culturally safe communication in healthcare. Yolŋu researchers (First Nations peoples from North-East Arnhem Land, NT, Australia) are prominent advocates for the bringing together of First Nations and White knowledge systems to learn from each other and collaborate respectfully (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). A participant in our previous research suggested a Yolŋu pathway for learning from each other, as a way to address miscommunication and co-create \u0026ldquo;a gold standard\u0026rdquo; in healthcare where Indigenous and non-Indigenous partners \u0026ldquo;can be together on the same level\u0026rdquo; (31, p7). The current study demonstrates that a training program, co-designed and co-delivered by First Nations and White facilitators, can stimulate healthcare provider critical reflection and support meaningful decolonising action. The challenge is to expand this collaborative transformation across healthcare systems and cultures.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eATS+\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAsk the Specialist Plus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCritical Race Theory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLearning Health System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNorthern Territory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRDH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRoyal Darwin Hospital\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval statement and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (HREC-22-4297) and the Research Governance Office, Northern Territory Department of Health (EFILE2022/13836).\u0026nbsp;The study was conducted in accordance with the Declaration of Helsinki guidelines. Study participants gave\u0026nbsp;written consent prior to participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe need for participant consent to complete surveys was waived by the Ethics Committee in keeping with the 2023 Australian National Statement on Ethical Conduct in Human Research (survey forms were completed anonymously and deemed highly unlikely to cause distress to participants).\u0026nbsp;All co-authors consented to publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from the study are not publicly available due to ethical considerations. Data may be available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting Interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study was funded by the Australian National Health and Medical Research Council (Partnership Grant, GNT2008644) and the Medical Research Futures Fund (Rapid Applied Research Translation, RARUR000143). Author APR was supported by a National Health and Medical Research Council Investigator Grant (GNT 2025371).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthor contributions\u003c/h2\u003e\n\u003cp\u003eVK, MH and APR designed the study. VK, TA and CC facilitated the training. Data collection and analysis was conducted by EA, TA, MS, MH, EJ and VK. \u0026nbsp;Drafting of the manuscript was led by EA with contributions from VK, TA, MS and MH. All authors contributed to manuscript revisions. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe Communicate Study Partnership acknowledges those who contributed to the delivery of Ask the Specialist Plus training. We thank ATS+ training co-facilitators: Candice McKenzie, Rachel Dikul Baker, Dr Aunty Bilawara Lee, Stuart Yiwarr McGath and Rarrtjiwuy Melanie Herdman. We also thank the NT Aboriginal Interpreter Service and Aboriginal Support Services Unit which includes Royal Darwin Hospitals Aboriginal Liaison Officers and Communicating for Safety Interpreters. We appreciate their contribution of time and expertise. Thank you to the healthcare providers who participated this evaluation by sharing their experiences and reflections. We acknowledge the guidance provided by Anne Lowell (Northern Institute, Charles Darwin University) and Alan Cass (Menzies School of Health Research) in early discussions of data analysis processes.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eThe Lancet. The soft science of medicine. The Lancet. 2004;363(9417):1247.\u003c/li\u003e\n \u003cli\u003eCurtis E, Loring B, Jones R, Tipene-Leach D, Walker C, Paine SJ, et al. Refining the definitions of cultural safety, cultural competency and Indigenous health: lessons from Aotearoa New Zealand. Int J Equity Health. 2025;24(1):130.\u003c/li\u003e\n \u003cli\u003eWatego C, Singh D, Macoun A. Partnership for justice in health: Scoping paper on race, racism and the Australian Health System. Melbourne: The Lowitja Institute; 2021. Available from: https://www.lowitja.org.au/wp-content/uploads/2023/05/Lowitja_PJH_170521_D10-1.pdf.\u003c/li\u003e\n \u003cli\u003eRamsden IM. Cultural Safety and Nursing Education in Aotearoa and Te Waipounamu: Victoria University of Wellington; 2002.\u003c/li\u003e\n \u003cli\u003eNorthern Territory Government. NT Aboriginal Health Plan 2021\u0026ndash;2031. Casuarina, NT: NT Health; 2021. Available from: https://health.nt.gov.au/professionals/aboriginal-and-torres-strait-islander-health/aboriginal-health-policy.\u003c/li\u003e\n \u003cli\u003eCommonwealth of Australia, Department of Health. Aboriginal and Torres Strait Islander health curriculum framework: Commonwealth of Australia; 2014. Available from: https://www.health.gov.au/resources/publications/aboriginal-and-torres-strait-islander-health-curriculum-framework.\u003c/li\u003e\n \u003cli\u003eAustralian Health Practitioner Regulation Agency (AHPRA). The National Scheme\u0026rsquo;s Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020\u0026ndash;2025 2020. Available from: https://apo.org.au/node/302976.\u003c/li\u003e\n \u003cli\u003eAustralian Government. National Aboriginal and Torres Strait Islander Health Plan 2021\u0026ndash; 2031. Canberra: Commonwealth of Australia; 2021. Available from: https://www.health.gov.au/resources/publications/national-aboriginal-and-torres-strait-islander-health-plan-2013-2023?language=en.\u003c/li\u003e\n \u003cli\u003eAustralian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. Sydney: Australian Commission on Safety and Quality in Health Care; 2021.\u003c/li\u003e\n \u003cli\u003eAustralian Human Rights Commission. The National Anti-Racism Framework: A roadmap to eliminating racism in Australia. 2024.\u003c/li\u003e\n \u003cli\u003eRalph AP, McGrath SY, Armstrong E, Herdman RM, Ginnivan L, Lowell A, et al. 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Available from: https://www.ntphn.org.au/wp-content/uploads/2021/11/map-of-major-aboriginal-languages.pdf. .\u003c/li\u003e\n \u003cli\u003eAustralian Bureau of Statistics. Language statistics for Aboriginal and Torres Strait Islander peoples 2021 [Available from: https://www.abs.gov.au/statistics/people/aboriginal-and-torres-strait-islander-peoples/language-statistics-aboriginal-and-torres-strait-islander-peoples/latest-release?utm_source=chatgpt.com.\u003c/li\u003e\n \u003cli\u003eAmery R. Recognising the communication gap in Indigenous health care. Medical Journal of Australia. 2017;207(1):13-5.\u003c/li\u003e\n \u003cli\u003eTaylor K, Guerin P. Health care and Indigenous Australians: Cultural safety in practice. . 2nd ed. South Yarra, VIC: Palgrave Macmillan; 2014.\u003c/li\u003e\n \u003cli\u003eMenzies School of Health Research. 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Batji-gum dilba (Good talk medicine): Improving culturally safe communication between doctors and Aboriginal patients in the Northern Territory of Australia [Doctoral thesis]. Darwin, NT: Menzies School of Health Research, Charles Darwin University; 2022.\u003c/li\u003e\n \u003cli\u003eVinson AH. Culture as infrastructure in learning health systems. Learn Health Syst. 2021;5(3):e10267.\u003c/li\u003e\n \u003cli\u003eEasterling D, Perry AC, Woodside R, Patel T, Gesell SB. Clarifying the concept of a learning health system for healthcare delivery organizations: Implications from a qualitative analysis of the scientific literature. Learn Health Syst. 2022;6(2):e10287.\u003c/li\u003e\n \u003cli\u003eRogers EM. Diffusion of innovations. 5th ed. New York: Free Press; 2003.\u003c/li\u003e\n \u003cli\u003eLowell A, Jones Y, Aitken R, Baker RD, Lovell J, Togni S, et al. Why surveys are \u0026lsquo;very hard\u0026rsquo;: Exploring challenges and insights for collection of authentic patient experience information with speakers of Australian First Nations languages. Rural and Remote Health. 2024;24(2):8380.\u003c/li\u003e\n \u003cli\u003eSena S, Armstrong E. Culturally congruent processes for collecting patient stories from speakers of Aboriginal languages in Central Australia. First Nations Health Communication Symposium Stories that matter: Reflecting and collaborating for change; Darwin and Alice Springs2025.\u003c/li\u003e\n \u003cli\u003eArmstrong E, Maypilama Ḻ, Bukulatjpi Y, Gapany D, Fasoli L, Ireland S, et al. Nhaltjan dhu ḻarrum ga dharaŋan dhuḏi-dh\u0026auml;wuw ŋunhi limurr dhu gumurrbunanhamirr ga waŋanhamirr, Yolŋu ga Balanda: How we come together to explore and understand intercultural communication through a Yolŋu (First Nations Australian) metaphor. AlterNative: An International Journal of Indigenous Peoples. 2023;19(2):334-44.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Healthcare provider training, Cultural safety, Intercultural communication, Anti-racism, Critical reflection, Learning health systems ","lastPublishedDoi":"10.21203/rs.3.rs-7826786/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7826786/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCultural safety and effective communication are essential to equitable quality healthcare. Cultural safety requires critical reflection - an active process which can be transformative when it supports a shift from awareness to practice change. Australian government departments, training organisations and regulation authorities require healthcare providers to complete cultural safety training but methods for effectively teaching critical reflection are not well described and evidence for their impact is limited. In Australia\u0026rsquo;s Northern Territory, a culturally safe communication training program called Ask the Specialist Plus (ATS+) was delivered as part of the Communicate Study Partnership. This study documents healthcare provider reflections on this locally-designed training.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA mixed methods approach included post-session participant surveys, pre and post training interviews, and participant observations. Survey participants provided free text responses and rated training sessions across five domains. Semi-structured interviews were conducted with purposefully sampled participants prior to the training and 3\u0026ndash;6 months after completion. Data was analysed using constructivist grounded theory to facilitate critical inquiry.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eData was collected from doctors, nurses, clinical managers, allied health professionals, medical imaging professionals and medical students. 337 surveys were collected, 30 interviews were conducted (15 pre-training and 15 post-training) and five staff were observed. Over 90% of survey participants agreed the training was relevant, engaging, supportive, and prompted reflection and change. Interview participants realised that their personal transformation and practice changes could make a difference to culturally safe communication and also identified departmental and hospital barriers. Reflection and action are evidenced by the gerunds and phrases ATS\u0026thinsp;+\u0026thinsp;participants used to describe training impacts: acknowledging, considering, reflecting, confronting, becoming aware, unpacking, interacting, building, creating, rearranging, implementing, making time, supporting, committing, realising, constraining, feeling powerless, doubting, taking responsibility and continuing.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003e ATS+, a locally-designed culturally safe communication training program co-delivered by First Nations and White facilitators in partnership, stimulated healthcare provider critical reflection and supported meaningful decolonising action. Learning Health System models offer pathways for addressing the structural and systemic barriers participants identified and for accelerating the translation of research into system-wide practice of cultural safety.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTrial registration\u003c/b\u003e\u003c/p\u003e \u003cp\u003eClinicalTrials.gov protocol ID NCT05629416\u003c/p\u003e","manuscriptTitle":"“You can do it in another way”: healthcare provider reflections on cultural safety training in Australia’s Northern Territory","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 09:27:43","doi":"10.21203/rs.3.rs-7826786/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-26T04:58:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231206777462579806354499058011790000625","date":"2025-12-17T16:11:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"17202392275377278200720786536561595593","date":"2025-12-15T12:23:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-15T11:00:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-08T19:44:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-18T07:02:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-18T06:39:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-11-18T06:34:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2732a5a4-6561-4a60-8e97-28ac1d4ed9ae","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T09:27:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-22 09:27:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7826786","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7826786","identity":"rs-7826786","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}