‘Walking Together in Aged Care’: The co-design and evaluation of an Aboriginal and Torres Strait Islander aged care training program

‘Walking Together in Aged Care’: The co-design and evaluation of an Aboriginal and Torres Strait Islander aged care training program | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article ‘Walking Together in Aged Care’: The co-design and evaluation of an Aboriginal and Torres Strait Islander aged care training program Jonathon Zagler, Tameeka Ieremia, Anna Dawson, Graham Aitken, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8437626/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Prior research has highlighted the critical need for targeted training to ensure the aged care workforce are equipped to respond effectively to the diverse and complex needs of Aboriginal and Torres Strait Islander peoples receiving aged care. Therefore, this study aimed to co-design, implement and evaluate a training program to strengthen the capacity of aged care workers to deliver culturally safe and responsive care to Aboriginal and Torres Strait Islander peoples. Methods The training program was developed through a mixed-method approach, undertaken using a community-based research framework where researchers worked in partnership with an Aboriginal community-controlled aged care organisation. This process included a literature review and survey to inform program content, followed by development workshops, an implementation pilot, and evaluation interviews with the aged care workforce across metropolitan, regional, and remote South Australia in 2024. Results A training program, titled Walking Together in Aged Care , was co-designed and centres the health, wellbeing and cultural needs of Aboriginal and Torres Strait Islander people receiving aged care and is relevant to workforce needs. Evaluation interviews revealed high course acceptability, key learnings, and considerations for scalability and applicability across diverse aged care settings. Conclusion Walking Together in Aged Care contributes significantly to the broader aim of addressing a lack of appropriate training programs for the aged care workforce delivering care to Aboriginal and Torres Strait Islander peoples. aged care workforce training co-design Aboriginal and Torres Strait Islander Figures Figure 1 Figure 2 1. Background Despite accessing aged care services at increasing rates, Aboriginal and Torres Strait Islander peoples, the First Peoples of Australia, remain underrepresented within the Australian aged care system [ 1 – 3 ]. This underrepresentation is shaped by a number of intersecting factors across aged care policy and practice, including the historical and ongoing impact of colonisation, an individualised and biomedical approach to service delivery, mistrust of services, experiences of racism and discrimination, a lack of continuity of care, an ad hoc service landscape, and funding and policy constraints [ 4 – 11 ]. There is growing understanding across research, policy and practice that Australia’s aged care system must be transformed to ensure equitable access to high quality, safe aged care services, regardless of cultural identity [ 2 , 3 , 5 , 12 , 13 ]. In response to the Royal Commission into Aged Care Quality and Safety , which concluded that the aged care system has failed to provide for the health, social and cultural needs of Aboriginal and Torres Strait Islander peoples, the Commonwealth have initiated significant reforms across the sector [ 13 , 14 ]. These reforms are critical to restoring dignity for those who have experienced historical trauma, upholding principles of self-determination and recognising the ongoing strengths of Aboriginal and Torres Strait Islander communities [ 15 ]. The aged care workforce, consisting of personal care workers, allied health professionals, administration, ancillary and informal care, have been positioned as central to this reform agenda [ 3 , 15 , 16 ]. This is reflected within the new Aged Care Quality Standards , which create a higher level of accountability for aged care providers to understand and deliver on the needs of Aboriginal and Torres Strait Islander peoples and acknowledge the need for a culturally responsive workforce [ 3 , 17 ]. While the strengthened Aged Care Quality Standards set clear expectations for culturally responsive care, their implementation will depend on a workforce that is adequately resourced and skilled to meet the health, wellbeing and cultural needs of Aboriginal and Torres Strait Islander peoples. However, without addressing the long-standing workforce challenges present across the sector [ 18 ], including the low proportion of Aboriginal and Torres Strait Islander workforce and the widespread lack of access to training programs that centre the health, wellbeing and cultural needs of Aboriginal and Torres Strait Islander peoples [ 3 , 5 , 19 ], progress will remain slow and ad hoc. This misalignment is reflected in current workforce training practices, which prioritise areas such as infection prevention and control, COVID-19, elder abuse, workplace health and safety and code of conduct, while culturally responsive care training remains insufficiently and inconsistently applied [ 3 , 16 ]. The result is a widening gap between policy commitments and the practical capacity of the aged care workforce to deliver culturally safe care. As such, there is an urgent need to partner with aged care organisations to develop training programs that focus on the experiences and needs of Aboriginal and Torres Strait Islander peoples, and that address both the practical and cultural dimensions of workforce development [ 19 – 21 ]. Wardliparingga Aboriginal Health Equity (Wardliparingga) within the South Australian Health and Medical Research Institute located on Kaurna Country (Adelaide, South Australia) undertakes research determined as priority by Aboriginal and Torres Strait Islander communities across South Australia [ 22 ]. Wardliparingga have over the past decade undertaken research relating to the ageing and aged care needs of Aboriginal and Torres Strait Islander peoples [ 5 ]. Throughout this research, Wardliparingga has partnered with Aboriginal Community Services (ACS), an Aboriginal community-controlled aged care organisation who, at the time of this study, were providing services to over 800 Aboriginal and Torres Strait Islander peoples across metropolitan, regional and remote South Australia [ 23 ]. Prior studies undertaken by Wardliparingga have highlighted the critical need for targeted training to ensure the workforce are equipped to respond effectively to the diverse and complex needs of Aboriginal and Torres Strait Islander peoples receiving aged care [ 4 , 5 , 7 , 19 ]. Thus, in 2023, Wardliparingga and ACS partnered to co-design and evaluate an aged care workforce training program that centres the health, wellbeing and cultural needs of Aboriginal and Torres Strait Islander peoples. This article outlines the co-design and evaluation of the Walking Together in Aged Care training program. Reflecting the participatory and iterative nature of the research, the paper is structured to follow the sequence of the co-design process itself. Each phase of the study informed and refined the next, beginning with a literature review and survey to guide content development, followed by collaborative workshops, implementation, and concluding with an evaluation of the training program. 2. Methods 2.1 Study Design The co-design and evaluation of the training program followed a community-based participatory research methodology, grounded in principles of collaboration, reciprocity, and shared decision-making [ 24 ]. This approach centred Aboriginal leadership and partnership, ensuring that the design, implementation and evaluation were informed by the priorities, knowledge, and cultural values of the partnering Aboriginal community-controlled aged care organisation. This project addresses the identified training needs of ACS and their workforce [ 19 ] and was collaboratively designed by ACS and Wardliparingga. Detailed and ongoing consultation occurred between ACS and Wardliparingga to determine research scope and activities over the life of the project. We used a co-design mixed methods approach including a literature review, workforce survey, development workshops, and evaluation interviews. The process was iterative, with cumulative findings informing subsequent stages of analysis. The methodological steps are presented in Fig. 1 . A Project Steering Committee (PSC) comprising community, workforce and research representatives, and a Chief Investigator Committee (CIC), provided authority over research direction, ensured the relevancy and appropriateness of research activities, and supported in the interpretation and dissemination of results. The PSC met four times during the research activities, in addition to JZ and TI meeting weekly between November 2023 and September 2024. The CIC met monthly during this same period. Each stage of the research was guided by the South Australian Aboriginal Health Research Ethics Accord [ 22 ], which sets out nine principles by which Aboriginal and Torres Strait Islander health research in South Australia should be conducted. We applied and followed the key principles and best practices for co-design in health with Aboriginal and Torres Strait Islander peoples [ 25 ]. Ethical approval to conduct this study was granted by the South Australian Aboriginal Health Research Ethics Committee (AHREC) in January 2024 (#04-23-1084). 2.2 Literature Review To provide a local perspective to the training program, a literature review was undertaken on Google Scholar in March 2024. Search terms included combinations of “Aboriginal”, “Indigenous”, “aged care”, “ageing”, “training”, and “workforce”. This search was extended to websites known to host information regarding Aboriginal and Torres Strait Islander health and wellbeing, including Australian Indigenous HealthInfoNet, Lowitja Institute, Department of Health and Aged Care, National Aboriginal and Torres Strait Islander Ageing and Aged Care Council, and Australian Association of Gerontology. Thematic analysis was undertaken in NVivo.12 [ 26 ] to identify key themes from the literature. Several themes were identified from the literature, which were aggregated into three categories: 1) Individual considerations, 2) Workplace and training, and 3) Funding and regulation. These findings were then used to inform the development of a training needs assessment survey questions and subsequent training program modules. Key themes are presented in Fig. 2 . 2.3 Workforce Survey To ensure a broad range of workforce perspectives were included in the development of the training program, a training needs assessment survey was distributed to Aboriginal community-controlled, not-for-profit and for-profit organisations providing aged care services to Aboriginal and Torres Strait Islander peoples across metropolitan, regional and remote South Australia [ 27 ]. The research team developed the survey questions collaboratively with input from the PSC and CIC. The survey, which collected both quantitative and qualitative responses, included questions that sought respondents’ views on training needs, training topics, and the structural, logistical, motivational enablers that supported participation in training, alongside potential barriers. Respondents reported a strong need for training across various topics, including social and emotional wellbeing, grief and loss, trauma-informed care, and healthy ageing. In-person training was the most preferred delivery mode, followed closely by a blended approach combining in-person and online. Among training components, case studies were the most favoured activity, followed closely by professional practice examples, videos, and opportunities to engage with local communities [ 27 ]. 2.4 Module Development The findings of the literature review, the preliminary survey results, and insights on training needs from the PSC and CIC, were triangulated to inform the initial design of the training modules, ensuring alignment with evidence-based practice and stakeholder priorities. From this, key aged care training topics emerged: Social and Emotional Wellbeing Ageing Well Trauma-informed Care Grief and Loss Cultural Safety, and Stolen Generation Survivorship Module development was an iterative process that saw the research team conduct literature scoping for content focused upon the specific topic. This approach involved repeated cycles of planning, prototyping, and structured feedback. The course content was developed to accommodate varying literacy and professional levels with the flexibility to break into smaller discrete subject groups. Permission was sought to use previously published videos and images, including those produced by Wardliparingga [ 28 ] and published illustrative quotes from community members involved in previous Wardliparingga aged care research [ 4 , 29 , 30 ] were incorporated throughout relevant modules. At key points throughout module development, two members of the research team (JZ, TI) reviewed each slide, validated the intended meaning of concepts and considered if images and videos were appropriate, and whether alternative methods were required to improve the teaching of key concepts. Once all information had been refined, the research team began developing these into interactive materials. This included developing strategies, informed by the literature review, to provide examples of how the workforce could implement content within their practice. For example, in the Social and Emotional Wellbeing module, the domain facilitating social connections included strategies such as co-designing and/or locating culturally safe social activities and embedding them within care plans [ 4 , 31 ]. Draft modules were distributed to health and aged care researchers employed by Wardliparingga with expertise in the module area, the PSC and CIC for review. Drawing on lived experience, the PSC offered an important perspective to ensure the content was relevant, clear and appropriate. Changes were made to the course materials based on feedback, with the updated versions also reviewed to ensure we captured and incorporated feedback correctly. 2.5 Development Workshops To ensure relevancy and applicability of content, and to co-design interactive module activities, the research team conducted group development workshops with ACS staff involved in the direct care or care coordination of clients across metropolitan, regional and remote South Australia. Following a purposive sampling strategy [ 32 ], all ACS staff involved in the direct care or care coordination and aged 18 years or over were invited to participate in a development workshop via an email invitation from the CEO. The email included a detailed study information statement outlining the research activities and a consent form. The CEO endorsed staff to participate during scheduled working hours. Potential participants were invited to contact the research team directly should they have any questions or require further information about the study or their participation. Informed consent was confirmed prior to the workshop by the facilitator verifying participants’ understanding of the study purpose and involvement. Each participant signed a consent form. We hosted three development workshops, two in-person and one online, in June and July 2024. Each workshop presented two modules and were co-facilitated by Aboriginal and/or Torres Strait Islander and non-Indigenous members of the research team. Each module was presented in PowerPoint form, with co-facilitators reading each slide and then inviting feedback. Each workshop included whole group discussions and breakout sessions where participants were divided into smaller groups. A workbook was provided to each participant at the beginning of each workshop where they could provide written responses. Workshops were not audio recorded however with participant consent written responses were collected at the end of each workshop. The hand-written data were scanned and imported onto a password-protected drive. Additionally, facilitators took hand-written notes throughout each workshop. All data were re-read, anonymised and transcribed verbatim before being synthesised and grouped together based on similarities. Feedback was then incorporated into each module. In total, n = 22 ACS staff participated across the three workshops. Participant demographics are presented in Table 1 . Each workshop ran for approximately 4 hours, which included a 30-minute lunch break. Feedback from participants across the workshops informed the refinement of the training program and revealed valuable insights. Participants emphasised the importance of culturally responsive and accessible design elements, highlighting the need for simplified information, plain language, and enhanced visual elements of Aboriginal and Torres Strait Islander cultures. Participants provided positive feedback on the draft interactive activities which supported diverse learning styles and the use of multimedia, community member quotes, and case-based learning. However, participants encouraged greater interactivity suggesting the use of pop-up diagrams, printable resources, and audio-visual content. Participants also indicated that the draft modules reflected their day-to-day practice and the challenges they face, including the incongruencies between aged care policy (e.g., the Aged Care Quality Standards) and practice and the fragmentation between aged care with other health and social services. Key recommendations are presented in Table 2 . Table 1 Pilot Workshop Participant Demographics Characteristic Total Role , Direct care 6 Care coordination 10 Management 3 Cultural and/or community engagement 3 Cultural identity Aboriginal and/or Torres Strait Islander 5 Non-Indigenous 17 Gender identity Women 17 Men 5 Number of years in aged care Less than 1 year 1 1–2 years 5 3–4 years 4 5–10 years 7 More than 10 years 5 Service type In-home 12 Residential 3 Both 7 Service delivery location Metropolitan 12 Regional and/or remote 2 Both 8 Table 2 Key recommendations from the pilot workshops Area Recommendations Design Greater use of colours, symbols, and artwork associated with Aboriginal and Torres Strait Islander cultures Improve sequencing of content to ensure that each topic builds upon the last to promote a holistic understanding Content and interactive activities Additional animated features including ‘pop-ups’, expandable diagrams, and interactive maps to reduce cognitive load Additional community member quotes, especially in video or narrated form to enhance emotional connection Development of additional case studies and role-specific examples to support applied learning Simplification of ‘slides’ with excessive text, replacing long paragraphs with dot points or visual representations Practice insights Ensure the inconsistencies between the Aged Care Quality Standards and providing care to Aboriginal and Torres Strait Islander peoples are reflected upon Highlight the importance of open communication, listening, and building trust with clients, particularly through yarning and storytelling as both assessment tools and healing practices Recognising systemic barriers (e.g., fragmented services, lack of service coordination) 2.6 Module Refinement and Distribution Once feedback from the development workshops had been integrated into each module, a final review of each module was undertaken by the research team before being uploaded into ACS’ Learning Management System. Each module was subsequently trialled by the PSC and research team. The name of the training program, Walking Together in Aged Care , emerged during a PSC meeting. In this discussion, a community member (NW) expressed that her aspiration for the program was to “teach aged care workers to walk alongside us within aged care.” This articulation reflected both the ethos and the intended objective of the program, grounding the title in the expressed priorities and lived experiences of community members. 2.7 Evaluation Interviews We then conducted a preliminary evaluation of the training program. All ACS staff aged 18 years or over, who were involved in the direct care of clients and who had completed the training program were invited to participate in a semi-structured evaluation interview via email invitation from the CEO, following the same processes as the workshop invitation. Informed consent was obtained prior to the interview by verifying participants’ understanding of the study purpose and involvement. Semi-structured evaluation interviews with ACS staff took place between December 2024 and February 2025. An evaluation interview guide was developed by the research team and PSC. With participant consent, all interviews were audio-recorded and transcribed verbatim by a third-party transcription service. Each participant was offered a copy of their transcript for review. The interview transcripts were de-identified using alpha-numeric codes to preserve the anonymity of participants. Using NVivo V.20, the transcripts were thematically analysed following Braun and Clarke’s approach (JZ, AP) [ 33 ]. Key themes were refined before being endorsed by the CIC. 3. Results 3.1 Implementation The training program, titled Walking Together in Aged Care , was launched organisation-wide in November 2024. The CEO encouraged all staff to complete the training program as part of their regular employment duties. As of August 2025, n = 125 ACS staff had commenced the Walking Together in Aged Care training program. This level of engagement highlights both ACS’ commitment to workforce development and the relevance of the training content to the needs and priorities of ACS. 3.2 Evaluation Interviews In total, six of 20 participants invited completed an evaluation interview. This included 4 women, 2 men, and 1 participant who identified as Aboriginal. The median age was 45.5 years. The number of years employed by ACS included less than one year (n = 2) , 1–2 years (n = 2) , 3–4 years (n = 1) , and more than 5 years (n = 1) . Work roles included direct care, care coordination and cultural and/or community engagement. Three participants completed the training one week prior to the interview, three weeks prior (n = 1) , and one month prior ( n = 2) to the interview. The interviews ranged from 25 minutes to 1 hour. From the thematic analysis, four themes were identified: 1) Designed for engagement and accessibility, 2) Navigating technical issues, 3) Learning outcomes and perceived impact, and 4) Considerations for scalability and adaptability. These themes are described in detail below, with additional illustrative quotes presented in Table 3 to provide further context. Table 3 Additional illustrative quotes Theme Illustrative quote Theme 1. Designed for engagement and accessibility • I like the matching [exercises], because that was more interactive. So that’s my auditory kinaesthetic side of things … The mixing and matching where you really got to stop to think about it … I found that I was learning multiple things at once then (Participant 6) • The next slide was like a heap of information, which was really good information, which would have been good to have before I got to the questions, because the information, I felt, from the questions was in the next slide after the questions … I just felt like a times there was information, I didn’t feel that it related directly to what you were asking (Participant 5) • I think the videos were good. I think it's good to hear from Elders (Participant 3) Theme 2. Navigating technical issues • I feel like the user friendliness again in technically, formatting wise. I don’t know, maybe it’s just ACS … It wouldn’t really work sometimes. So, you kept on going back and forth so it wasn’t friendly in that way (Participant 3) • I guess in the future we’ll need to be ready for the glitches and stuff (Participant 2) Theme 3. Learning outcomes and perceived impact • It was an eye-opener, not having been exposed to anything like that before. Some of the information was a little bit confronting, but it sorts of opened my eyes to, you know, what happened … I could only imagine some of the trauma that’s been, you know, felt through the generations. It’s made me want to learn more (Participant 4) • I really enjoyed it. I got a lot out of it, and I thought I knew a lot about First Nation people, but I’ve learned so much more… It’s good that you’re finally getting courses out there like this because, as I said, I have not in the last twenty years of doing this topic, had anything that’s really come directly from the people we’re trying to look after (Participant 1) • I think it's [the training] needed. And I do think that people who provide, services to Indigenous people need more training and I do think there needs to be a lot more understanding to be able to provide services in a way that's culturally appropriate, and that they feel safe and secure enough to talk to you about stuff as well … So, I do think there is a huge need for the training. Those things would be great for someone who's never worked in an Aboriginal organisation. … So, you know, it really made an impact for me, and that's why, I guess, I'm very, um, I guess, passionate about seeing something like this (Participant 6) Theme 4. Future directions for scaling and adapting the training program • Everyone in the organisation, and it's not just the people, like, who have contact with the Elders. Like, I still think even, like, the management people up here as well, because they also need to understand, because then they need to understand where, at times, that we're coming from, as to why something needs to be done a certain way, as to why, you know, we can't do it like ABC. We need to go to A and then D and then, you know, like, back to B you know because that's going to work better. So, I think, you know, and I think you should also roll it out to the government (Participant 5) • I could see you splitting them out and doing some of them individually … Looking at [each module] in relation to what your staff need and identifying any issues or gaps, and then there might be a gap in relation to one part of that training that you could certainly use … I was learning so much in that period; I think it was probably hard to digest everything ... And then you’re more focused (Participant 1) Theme 1. Designed for engagement and accessibility Participants highlighted the flexible, modular structure of the training program as a key strength. The sequential design, with each module building upon the last, was highlighted for its holistic approach to learning. Participants appreciated being able to complete the training program at their own pace, with the ability to pause and return allowing them to balance workplace demands. The mixture of interactive activities (e.g., videos, case studies, and multiple-choice) and written information was positively received, effectively conveying key messages and removing barriers to engagement. Each module sort of like fed into the next, which was nice … And you know, you certainly didn’t have to do it all at once and they were small enough, each module, that you could perhaps do a couple and then maybe a couple the next day. And I didn’t think there was too much reading. I thought there was just enough to give you a really good idea of … the message you were trying to get across. I thought it gave you the right amount of information. Some training courses I find don’t give you enough … to give you a holistic picture of what you’re trying to do (Participant 1) The training was enriched through inclusion of digital content where local Elders described their real-life experiences. This added authenticity, particularly in culturally sensitive areas, and multiple-choice questions were noted for promoting active learning. However, there were calls to expand interactivity further. Additionally, the open-ended strategy-based questions were described as challenging or confusing, particularly when prompts felt vague or overly broad. Participants suggested rewording them to enhance clarity, incorporate role-specific responses, and to ensure that they had received the information required to answer such questions. They gave a statement, and now it’s over to you to write a strategy and you’re sort of like a bit lost. Like, what do I write? I feel like there could have been one or two questions and maybe an example, and then okay, that's what they want me to do … So, it wasn’t friendly in terms of what they wanted you to write … I think you need more of a promoting question rather than a statement (Participant 3) Theme 2. Navigating technical issues Participants encountered several technological issues when completing the training program which impacted their ability to complete all modules efficiently. Reports of ‘glitches’, including blank slides, being unable to progress past certain points, and written responses failing to register within the LMS, prevented progress. Despite efforts to address these glitches, participants noted that the system remained unreliable and difficult to use. However, participants emphasised that these challenges were not a reflection of the training program’s design, but instead due to limitations of the training platform used by the organisation. I just found the system a little bit hard to use … But I worked that out quickly. That’s [the technology] something that can certainly be improved. It’s just the training system we use … That was the only thing that frustrated the kajeebies out of me (Participant 1) Theme 3. Learning outcomes and perceived impact Participants reported initial positive learning outcomes and found the training program highly valuable and relevant to their roles. For some, it served as a refresher; for others, it opened new areas of understanding and confidence to provide culturally safe care. All however appreciated the opportunity to deepen their knowledge and reflect on their practice. It did make you think of what we could do as an organisation, to support Elders through everything … If we’re implementing a social support program, we can look at learning from this, how we make it culturally safe and a safe place for Elders to speak if they need to. I think it makes you think how can we do things better. What are we missing? What can we do? (Participant 3) They emphasised the importance of ongoing engagement with the training program to continue expanding their understanding, assessing existing practices and to identify gaps and areas for improvement, and applying their learnings in their work. Key learnings surrounded the needs of Stolen Generation Survivors, grief and loss, and intergenerational trauma, though participants noted a need for additional information on specific cultural groups, Advance Care Planning, and one-on-one interactions. Many shared what they had learned with their colleagues, valuing collective learning and collaboration, and noted that the training helped break down stigma around sensitive topics, and contribute to trust and rapport-building. Ultimately, the program was viewed as a crucial step toward embedding culturally responsive practices in aged care. I do think there needs to be a lot more understanding to be able to provide services in a way that's culturally appropriate, and that they feel safe and secure enough to talk to you about stuff as well, because they need to feel comfortable enough to talk to you. So, I do think there is a huge need for the training (Participant 5) Theme 4. Future directions for scaling and adapting the training program Participants highlighted key considerations for scaling and adapting the training program beyond its initial implementation. Several noted that similar programs were lacking in, making this training unique and necessary. Participants emphasised that the training would be beneficial for a broad range of staff, not just those in direct care roles, as having a consistent and shared understanding would enhance the quality of care being provided. Reflecting on their clients’ negative experiences with other organisations, there was strong consensus that the training program be rolled out to all organisations providing services to older Aboriginal and Torres Strait Islander people to address their experiences of racism and the lack of cultural safety. This would help foster respect across the broader sector. Participants not only endorsed its continuation but also advocated for its wider implementation to ensure that more professionals benefit from its insights and practical applications. I think if you’re working for an Aboriginal organisation – it doesn’t matter what your role is, you need to have a broad understanding of what it is we do here. I don’t care whether you’re in finance or you’re the janitor, like you need to know, it’s across the board. I think it’s important if we’re all in aged care, this [the training program] should be rolled out to all the aged care providers, because it’s specific (Participant 6) Moreover, participants emphasised the need for additional flexibility in the delivery of the program, highlighting the benefits of incorporating group-based and face-to-face learning alongside digital formats. While the online modules were praised for their accessibility, they were not considered sufficient on their own. Incorporating different delivery modes would provide a richer learning experience where recipients could ask questions in real-time, engage in discussions, and seek clarification on complex topics, and thus foster a sense of shared learning. A blended approach, where organisations begin with digital content before transitioning into face-to-face sessions, would facilitate this. I would maybe suggest a team environment, because it’s always good to have a conversation with people, because someone’s got a different experience to yourself, the person on the left of you, to the right of you. I think if you had some of the Elders involved as well, I think that would be good … If you’re in a situation where you can have a conversation with someone, they might be able to offer a bit more of an explanation to better understand the situation (Participant 4) 4. Discussion Developed through a co-design process with ACS, Walking Together in Aged Care responds directly to the urgent need for comprehensive, tailored and culturally grounded workforce development strategies to promote positive aged care outcomes for Aboriginal and Torres Strait Islander peoples [ 5 , 19 , 34 ]. The training program was purposefully designed to equip the aged care workforce with the knowledge, skills and confidence to deliver care that is trauma-informed, culturally safe, and responsive to the health, wellbeing and cultural needs of Aboriginal and Torres Strait Islander peoples. While much of the current aged care training landscape remains oriented towards task-based competencies [ 3 ], this training program enhances this by incorporating the relational, ethical, and cultural dimensions of care – dimensions which are often undervalued but are central to the health and wellbeing of Aboriginal and Torres Strait Islander peoples. In doing so, it responds to the call from the Royal Commission into Aged Care Quality and Safety for a fundamental shift in how the workforce is supported to provide care that upholds dignity, rights and cultural identities [ 13 ]. Interviews indicate that Walking Together in Aged Care has contributed to increased workforce confidence in providing culturally safe and responsive care. Participants reported that the training program would support them in building trust and rapport with their clients, in critical reflection, and promote learning in priority areas identified by Aboriginal and Torres Strait Islander peoples, including ageing well, social and emotional wellbeing and grief and loss. Central to this success was the flexible, modular and self-paced delivery, and the range of interactive activities which accommodated varying literacy levels and learning styles. Such delivery methods may address key factors associated with workforce retention, including burnout, which are acute in resource-constrained settings [ 20 , 21 , 35 , 36 ]. Furthermore, there was strong endorsement that the training program be made available across the sector, reaching not only frontline workers, but also those in ancillary, administrative and management roles. This highlights that culturally safe care is not the sole responsibility of frontline workers but rather depends on the capacity of the entire service system to respond in relational, ethical and culturally informed ways – with each point of interaction contributing to care experiences and outcomes. This extends to those working in policy, commissioning and regulatory roles, who may shape the conditions under which aged care is being delivered [ 5 ]. Too often, aged care workers are required to adopt a model of care ill-suited to Aboriginal and Torres Strait Islander peoples which places additional burden on the workforce [ 4 , 5 , 19 , 37 ]. As identified in this study, Walking Together in Aged Care presents a critical mechanism to promote a shared understanding between workforce employed across all levels of the aged care sector, which may lead to practice and policy decisions that better reflect the needs of Aboriginal and Torres Strait Islander peoples. Participant feedback highlighted a clear need for a blended modalities of online content with face-to-face learning. This aligns with the broader consensus that while digital learning can expand reach and accessibility, it is through interpersonal connection and dialogue that deeper, practice-level transformations are most effectively achieved [ 20 , 21 ]. At the same time, online training remains a practical and viable option for workforce and even more so for those in geographically isolated areas. The primarily online delivery of this training program highlighted persistent inequities in digital infrastructure across the sector, including access to adequate technology, stable internet and IT support, which disproportionately impact underfunded and geographically isolated services [ 38 – 41 ]. Therefore, as aged care reforms increasingly prioritise workforce training and development, they must address not only what is delivered, but how training across regions can be equitably accessed and sustained. Walking Together in Aged Care contributes significantly to the broader aim of building a workforce with the knowledge, skills and confidence to support the growing number of Aboriginal and Torres Strait Islander peoples accessing aged care [ 3 , 15 ] which now includes Stolen Generation Survivors who may require additional healthy ageing and care considerations, including trauma-informed supports [ 42 ]. It also responds to the reality that health and aged care is delivered across both Aboriginal-specific and mainstream services, necessitating a consistent standard of care irrespective of service context [ 1 ]. Further, considering the ongoing underrepresentation of Aboriginal and Torres Strait Islander peoples employed across the aged care sector, the training program affirms the critical role of the non-Indigenous workforce in advancing culturally safe care. Rather than positioning cultural safety as the sole responsibility of Aboriginal and Torres Strait Islander workers, the training supports a shared workforce responsibility and ensures non-Indigenous staff are equipped [ 3 , 4 , 43 ]. Broadly, this study affirms the value of co-design as a powerful and necessary strategy to navigate the complex terrain of innovation across the aged care sector, where systemic constraints and service pressures can often inhibit the adoption of new practices [ 21 , 44 ]. Rather than imposing external solutions, our co-design approach which closely aligned with the key principles of co-design in Aboriginal and Torres Strait Islander health allowed for innovation to emerge from within the sector, tailored to context, guided by community and informed by practice [ 25 ]. The value of this approach is well established in the literature, which underscores training programs are more likely to be adopted, effective, and sustained when they reflect the values and practices of those they are intended to serve [ 45 – 47 ]. 4.1 Strengths and Limitations This study has several key strengths. Our partnership with ACS, the major provider of aged care for Aboriginal and Torres Strait Islander peoples in South Australia, ensured strong alignment with community-identified priorities and existing workforce development strategies. This partnership facilitated a structured framework for meaningful engagement and implementation with a broad range of staff, ensuring contextual relevance and practical applicability of the training program. Moreover, the design of the training program was largely informed by prior research undertaken by Wardliparingga. This evidence base provided a strong foundation for identifying training needs in addition to core components of ageing well and aged care for community members in South Australia. While only a preliminary evaluation of the pilot program was undertaken, early implementation data such as this is important in understanding the initial reach of the program and provides a foundation for future evaluation of its impact and scalability across the broader aged care sector. While efforts were made to engage widely with the remote workforce, time and resourcing constraints restricted the depth and breadth of engagement within remote regions. Additionally, while the survey component extended beyond ACS, the remainder of the study activities were undertaken exclusively with ACS. This strengthened the training programs’ localised focus but limits its broader generalisability. 4.2 Future Directions Building on the outcomes of this study, future phases will focus on scaling the training program to a broader range of organisations and service settings to ensure relevancy and applicability. A key focus will be ongoing engagement with Aboriginal and Torres Strait Islander communities in South Australia in the development of videos and case studies, and with the remote workforce who have distinct cultural, logistical and service delivery considerations that require sustained engagement strategies. These contributions are essential to ensuring that the training program remains grounded in lived experience and reflects workforce needs in local area contexts. To promote long-term sustainability, integration of the training program into accredited training and formal qualifications will be explored in collaboration with the Vocational Education and Training (VET) sector, Registered Training Organisations (RTOs), and peak training bodies. 5. Conclusion As health and aged care systems contend with population ageing, increasing care demands, and ongoing reforms, there is an urgent need to develop training programs that reflect the perspectives of both those receiving and delivering care. This study demonstrates that meaningful workforce development, designed by, with and for Aboriginal and Torres Strait Islander communities and the aged care workforce, is an essential component to achieving equity in aged care. The Walking Together in Aged Care training program presents a compelling model of locally grounded, culturally informed training which may help address systemic barriers, foster culturally safe care, and respond to the complex realities faced by clients and staff alike. In this context, training must be recognised not simply as professional development, but as a critical lever for health equity and an act of systemic repair and responsibility. Embedding community and workforce informed training within national workforce strategies will be essential to achieving the goals of aged care reforms. Programs like this may offer a clear path forward – grounded in self-determination, community knowledge, and a commitment to equitable care. Declarations Ethics approval and consent to participate Ethical approval to conduct this study was granted by the South Australian Aboriginal Health Research Ethics Committee (AHREC) (#04-23-1084). All participants provided written informed consent. All research procedures involving human participants were conducted in accordance with the principles of the Declaration of Helsinki and with relevant national ethical guidelines for research involving Aboriginal and Torres Strait Islander peoples. Consent for publication Not applicable Competing interests The authors declare no conflict of interest. Funding This work was supported by Aged Care Research and Industry Innovation Australia (ARIIA) (#GA00075) and Medical Research Futures Fund (MRFF) (GNT: 2024389). OP was supported by a National Health and Medical Research Investigator Grant (GNT: 2026852). Author Contribution JZ: Conceptualisation; Methodology; Formal Analysis; Investigation; Resources; Writing – Original Draft; Writing – Review and Editing; Visualization; Supervision; Project Administration; Funding acquisition. TI: Conceptualisation; Investigation; Writing – Review and Editing. AD: Conceptualisation; Methodology; Writing – Review and Editing; Supervision; Funding acquisition. GA: Conceptualisation; Writing – Review and Editing; Supervision; Funding acquisition. CD: Formal analysis; Writing – Review and Editing; Project administration. NW: Formal analysis; Writing – Review and Editing. JM: Formal analysis; Writing – Review and Editing. AP: Conceptualisation; Methodology; Formal Analysis; Investigation; Resources; Supervision; Project Administration; Funding acquisition; Writing – Review and Editing. OP: Conceptualisation; Methodology; Formal Analysis; Investigation; Resources; Supervision; Project Administration; Funding acquisition; Writing – Review and Editing Acknowledgement The authors would like to acknowledge and pay their respects to the Traditional Owners of the lands on which this research was conducted. We pay our respects to Elders past, present and future. We extend our gratitude to the study participants for sharing their experiences and views, our partnership with ACS, and the PSC who provided governance and advice. Data Availability Data from this study are not available due to the sensitive nature of the content discussed. References Australian Institute of Health and Welfare. Aged care for First Nations people. 2023 [cited 2024; Available from: https://www.aihw.gov.au/reports/australias-welfare/aged-care-for-indigenous-australians#aged-care-services Pearson O, et al. Aged care service use by Aboriginal and Torres Strait Islander people after aged care eligibility assessment, 2017–2019: a population-based retrospective cohort study. Med J Australia. 2024;221(1):31–7. Kelly A. Transforming Aged Care for Aboriginal and Torres Strait Islander people. ACT: Canberra; 2024. Pearson O, et al. 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QSR International Pty Ltd. NVivo. QSR International Pty Ltd.; 2022. Parrella A, et al. Training needs of the aged care workforce providing services to Aboriginal and Torres Strait Islander peoples in South Australia: A cross-sectional survey. medRvix; 2025. Wardliparingga Aboriginal Health Equity. Wellbeing in Homecare Study. 2023 [cited 2024 August 1]; Available from: https://sahmri.org.au/research/themes/aboriginal-health/programs/population-health/projects/wellbeing-in-homecare-study Zagler J, et al. Barriers and enablers to supporting the healthy ageing needs of Aboriginal and Torres Strait Islander peoples within aged care: A qualitative study. Under review; 2025. Brown A, et al. Healthy Ageing in Aged Care Study Community Report: Stage One. Adelaide, South Australia: South Australian Health and Medical Research Institute; 2021. pp. 1–8. Gee G et al. 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Jamieson SK et al. A Community-Led Approach to Understanding How Service Providers Can Support 'Ageing well' for Older Aboriginal People in Australia. J Gerontol Soc Work, 2025: pp. 1–28. Thompson SC et al. Engaging Health and Aged Care Workers in Rural and Remote Australia Around Factors Impacting Their Access to and Participation in Dementia Training. Geriatr (Basel), 2025. 10(1). Pearson LH. C., Partners in health to eLearning module development in rural and remote Western Australia. National Rural Health Alliance; 2019. pp. 1–10. Stack J. Opinion: Why aged care can't afford eLearning . 2024 16 May 2025]; Available from: https://insideageing.com.au/opinion-why-aged-care-cant-afford-elearning/ National Aboriginal Community Controlled Health Organisation, Indigenous Digital Inclusion Plan - Discussion Paper. 2021, National Aboriginal Community Controlled Health Organisation,. pp. 1–6. Foundation H. Are you waiting for us to die?' The unfinished business of Bringing Them Home. Healing Foundation; 2025. pp. 1–48. Zagler J, Yu N, Cleland A. The system allows for it to happen: the experiences of human service workers in engaging with Aboriginal participants of the National Disability Insurance Scheme. Disabil Rehabil, 2024: pp. 1–9. Windle A, et al. Factors that influence the implementation of innovation in aged care: a scoping review. JBI Evid Implement; 2023. Dopp AR, et al. Integrating implementation and user-centred design strategies to enhance the impact of health services: protocol from a concept mapping study. Health Res Policy Syst. 2019;17(1):1. Janamian T, et al. Co-creating education and training programs that build workforce capacity to support the implementation of integrated health care initiatives. Med J Aust. 2022;216(Suppl 10):S9–13. van Gemert-Pijnen JE, et al. A holistic framework to improve the uptake and impact of eHealth technologies. J Med Internet Res. 2011;13(4):e111. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8437626","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":576438070,"identity":"06594ef6-231c-4f47-9d81-d5cf8ae52e98","order_by":0,"name":"Jonathon 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2","display":"","copyAsset":false,"role":"figure","size":143250,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eKey themes identified through literature review\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8437626/v1/0c7e2e0db8207b64ef5300e1.jpg"},{"id":100756571,"identity":"31eafc94-467c-44f2-8aee-89fcc7baf814","added_by":"auto","created_at":"2026-01-21 06:36:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1118552,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8437626/v1/d609789a-0282-457d-b624-a47505fed852.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"‘Walking Together in Aged Care’: The co-design and evaluation of an Aboriginal and Torres Strait Islander aged care training program","fulltext":[{"header":"1. Background","content":"\u003cp\u003eDespite accessing aged care services at increasing rates, Aboriginal and Torres Strait Islander peoples, the First Peoples of Australia, remain underrepresented within the Australian aged care system [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This underrepresentation is shaped by a number of intersecting factors across aged care policy and practice, including the historical and ongoing impact of colonisation, an individualised and biomedical approach to service delivery, mistrust of services, experiences of racism and discrimination, a lack of continuity of care, an ad hoc service landscape, and funding and policy constraints [\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9 CR10\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. There is growing understanding across research, policy and practice that Australia\u0026rsquo;s aged care system must be transformed to ensure equitable access to high quality, safe aged care services, regardless of cultural identity [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn response to the \u003cem\u003eRoyal Commission into Aged Care Quality and Safety\u003c/em\u003e, which concluded that the aged care system has failed to provide for the health, social and cultural needs of Aboriginal and Torres Strait Islander peoples, the Commonwealth have initiated significant reforms across the sector [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These reforms are critical to restoring dignity for those who have experienced historical trauma, upholding principles of self-determination and recognising the ongoing strengths of Aboriginal and Torres Strait Islander communities [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The aged care workforce, consisting of personal care workers, allied health professionals, administration, ancillary and informal care, have been positioned as central to this reform agenda [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This is reflected within the new \u003cem\u003eAged Care Quality Standards\u003c/em\u003e, which create a higher level of accountability for aged care providers to understand and deliver on the needs of Aboriginal and Torres Strait Islander peoples and acknowledge the need for a culturally responsive workforce [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile the strengthened \u003cem\u003eAged Care Quality Standards\u003c/em\u003e set clear expectations for culturally responsive care, their implementation will depend on a workforce that is adequately resourced and skilled to meet the health, wellbeing and cultural needs of Aboriginal and Torres Strait Islander peoples. However, without addressing the long-standing workforce challenges present across the sector [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], including the low proportion of Aboriginal and Torres Strait Islander workforce and the widespread lack of access to training programs that centre the health, wellbeing and cultural needs of Aboriginal and Torres Strait Islander peoples [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], progress will remain slow and ad hoc. This misalignment is reflected in current workforce training practices, which prioritise areas such as infection prevention and control, COVID-19, elder abuse, workplace health and safety and code of conduct, while culturally responsive care training remains insufficiently and inconsistently applied [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The result is a widening gap between policy commitments and the practical capacity of the aged care workforce to deliver culturally safe care. As such, there is an urgent need to partner with aged care organisations to develop training programs that focus on the experiences and needs of Aboriginal and Torres Strait Islander peoples, and that address both the practical and cultural dimensions of workforce development [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWardliparingga Aboriginal Health Equity (Wardliparingga) within the South Australian Health and Medical Research Institute located on Kaurna Country (Adelaide, South Australia) undertakes research determined as priority by Aboriginal and Torres Strait Islander communities across South Australia [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Wardliparingga have over the past decade undertaken research relating to the ageing and aged care needs of Aboriginal and Torres Strait Islander peoples [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Throughout this research, Wardliparingga has partnered with Aboriginal Community Services (ACS), an Aboriginal community-controlled aged care organisation who, at the time of this study, were providing services to over 800 Aboriginal and Torres Strait Islander peoples across metropolitan, regional and remote South Australia [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Prior studies undertaken by Wardliparingga have highlighted the critical need for targeted training to ensure the workforce are equipped to respond effectively to the diverse and complex needs of Aboriginal and Torres Strait Islander peoples receiving aged care [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Thus, in 2023, Wardliparingga and ACS partnered to co-design and evaluate an aged care workforce training program that centres the health, wellbeing and cultural needs of Aboriginal and Torres Strait Islander peoples.\u003c/p\u003e \u003cp\u003eThis article outlines the co-design and evaluation of the \u003cem\u003eWalking Together in Aged Care\u003c/em\u003e training program. Reflecting the participatory and iterative nature of the research, the paper is structured to follow the sequence of the co-design process itself. Each phase of the study informed and refined the next, beginning with a literature review and survey to guide content development, followed by collaborative workshops, implementation, and concluding with an evaluation of the training program.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design\u003c/h2\u003e \u003cp\u003eThe co-design and evaluation of the training program followed a community-based participatory research methodology, grounded in principles of collaboration, reciprocity, and shared decision-making [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This approach centred Aboriginal leadership and partnership, ensuring that the design, implementation and evaluation were informed by the priorities, knowledge, and cultural values of the partnering Aboriginal community-controlled aged care organisation. This project addresses the identified training needs of ACS and their workforce [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and was collaboratively designed by ACS and Wardliparingga. Detailed and ongoing consultation occurred between ACS and Wardliparingga to determine research scope and activities over the life of the project. We used a co-design mixed methods approach including a literature review, workforce survey, development workshops, and evaluation interviews. The process was iterative, with cumulative findings informing subsequent stages of analysis. The methodological steps are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e A Project Steering Committee (PSC) comprising community, workforce and research representatives, and a Chief Investigator Committee (CIC), provided authority over research direction, ensured the relevancy and appropriateness of research activities, and supported in the interpretation and dissemination of results. The PSC met four times during the research activities, in addition to JZ and TI meeting weekly between November 2023 and September 2024. The CIC met monthly during this same period. Each stage of the research was guided by the South Australian Aboriginal Health Research Ethics Accord [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], which sets out nine principles by which Aboriginal and Torres Strait Islander health research in South Australia should be conducted. We applied and followed the key principles and best practices for co-design in health with Aboriginal and Torres Strait Islander peoples [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Ethical approval to conduct this study was granted by the South Australian Aboriginal Health Research Ethics Committee (AHREC) in January 2024 (#04-23-1084).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Literature Review\u003c/h2\u003e \u003cp\u003eTo provide a local perspective to the training program, a literature review was undertaken on Google Scholar in March 2024. Search terms included combinations of \u0026ldquo;Aboriginal\u0026rdquo;, \u0026ldquo;Indigenous\u0026rdquo;, \u0026ldquo;aged care\u0026rdquo;, \u0026ldquo;ageing\u0026rdquo;, \u0026ldquo;training\u0026rdquo;, and \u0026ldquo;workforce\u0026rdquo;. This search was extended to websites known to host information regarding Aboriginal and Torres Strait Islander health and wellbeing, including Australian Indigenous HealthInfoNet, Lowitja Institute, Department of Health and Aged Care, National Aboriginal and Torres Strait Islander Ageing and Aged Care Council, and Australian Association of Gerontology. Thematic analysis was undertaken in NVivo.12 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] to identify key themes from the literature. Several themes were identified from the literature, which were aggregated into three categories: 1) Individual considerations, 2) Workplace and training, and 3) Funding and regulation. These findings were then used to inform the development of a training needs assessment survey questions and subsequent training program modules. Key themes are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Workforce Survey\u003c/h2\u003e \u003cp\u003eTo ensure a broad range of workforce perspectives were included in the development of the training program, a training needs assessment survey was distributed to Aboriginal community-controlled, not-for-profit and for-profit organisations providing aged care services to Aboriginal and Torres Strait Islander peoples across metropolitan, regional and remote South Australia [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The research team developed the survey questions collaboratively with input from the PSC and CIC. The survey, which collected both quantitative and qualitative responses, included questions that sought respondents\u0026rsquo; views on training needs, training topics, and the structural, logistical, motivational enablers that supported participation in training, alongside potential barriers. Respondents reported a strong need for training across various topics, including social and emotional wellbeing, grief and loss, trauma-informed care, and healthy ageing. In-person training was the most preferred delivery mode, followed closely by a blended approach combining in-person and online. Among training components, case studies were the most favoured activity, followed closely by professional practice examples, videos, and opportunities to engage with local communities [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Module Development\u003c/h2\u003e \u003cp\u003eThe findings of the literature review, the preliminary survey results, and insights on training needs from the PSC and CIC, were triangulated to inform the initial design of the training modules, ensuring alignment with evidence-based practice and stakeholder priorities. From this, key aged care training topics emerged:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSocial and Emotional Wellbeing\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAgeing Well\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTrauma-informed Care\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGrief and Loss\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCultural Safety, and\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStolen Generation Survivorship\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eModule development was an iterative process that saw the research team conduct literature scoping for content focused upon the specific topic. This approach involved repeated cycles of planning, prototyping, and structured feedback. The course content was developed to accommodate varying literacy and professional levels with the flexibility to break into smaller discrete subject groups. Permission was sought to use previously published videos and images, including those produced by Wardliparingga [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and published illustrative quotes from community members involved in previous Wardliparingga aged care research [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] were incorporated throughout relevant modules. At key points throughout module development, two members of the research team (JZ, TI) reviewed each slide, validated the intended meaning of concepts and considered if images and videos were appropriate, and whether alternative methods were required to improve the teaching of key concepts.\u003c/p\u003e \u003cp\u003eOnce all information had been refined, the research team began developing these into interactive materials. This included developing strategies, informed by the literature review, to provide examples of how the workforce could implement content within their practice. For example, in the Social and Emotional Wellbeing module, the domain \u003cem\u003efacilitating social connections\u003c/em\u003e included strategies such as co-designing and/or locating culturally safe social activities and embedding them within care plans [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Draft modules were distributed to health and aged care researchers employed by Wardliparingga with expertise in the module area, the PSC and CIC for review. Drawing on lived experience, the PSC offered an important perspective to ensure the content was relevant, clear and appropriate. Changes were made to the course materials based on feedback, with the updated versions also reviewed to ensure we captured and incorporated feedback correctly.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Development Workshops\u003c/h2\u003e \u003cp\u003eTo ensure relevancy and applicability of content, and to co-design interactive module activities, the research team conducted group development workshops with ACS staff involved in the direct care or care coordination of clients across metropolitan, regional and remote South Australia. Following a purposive sampling strategy [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], all ACS staff involved in the direct care or care coordination and aged 18 years or over were invited to participate in a development workshop via an email invitation from the CEO. The email included a detailed study information statement outlining the research activities and a consent form. The CEO endorsed staff to participate during scheduled working hours. Potential participants were invited to contact the research team directly should they have any questions or require further information about the study or their participation. Informed consent was confirmed prior to the workshop by the facilitator verifying participants\u0026rsquo; understanding of the study purpose and involvement. Each participant signed a consent form.\u003c/p\u003e \u003cp\u003eWe hosted three development workshops, two in-person and one online, in June and July 2024. Each workshop presented two modules and were co-facilitated by Aboriginal and/or Torres Strait Islander and non-Indigenous members of the research team. Each module was presented in PowerPoint form, with co-facilitators reading each slide and then inviting feedback. Each workshop included whole group discussions and breakout sessions where participants were divided into smaller groups. A workbook was provided to each participant at the beginning of each workshop where they could provide written responses. Workshops were not audio recorded however with participant consent written responses were collected at the end of each workshop. The hand-written data were scanned and imported onto a password-protected drive. Additionally, facilitators took hand-written notes throughout each workshop. All data were re-read, anonymised and transcribed verbatim before being synthesised and grouped together based on similarities. Feedback was then incorporated into each module.\u003c/p\u003e \u003cp\u003eIn total, \u003cem\u003en\u0026thinsp;=\u0026thinsp;22\u003c/em\u003e ACS staff participated across the three workshops. Participant demographics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Each workshop ran for approximately 4 hours, which included a 30-minute lunch break. Feedback from participants across the workshops informed the refinement of the training program and revealed valuable insights. Participants emphasised the importance of culturally responsive and accessible design elements, highlighting the need for simplified information, plain language, and enhanced visual elements of Aboriginal and Torres Strait Islander cultures. Participants provided positive feedback on the draft interactive activities which supported diverse learning styles and the use of multimedia, community member quotes, and case-based learning. However, participants encouraged greater interactivity suggesting the use of pop-up diagrams, printable resources, and audio-visual content. Participants also indicated that the draft modules reflected their day-to-day practice and the challenges they face, including the incongruencies between aged care policy (e.g., the Aged Care Quality Standards) and practice and the fragmentation between aged care with other health and social services. Key recommendations are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\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\u003e\u003cem\u003ePilot Workshop Participant Demographics\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRole\u003c/em\u003e,\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCare coordination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCultural and/or community engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCultural identity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAboriginal and/or Torres Strait Islander\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Indigenous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender identity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of years in aged care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eService type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eService delivery location\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetropolitan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegional and/or remote\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \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\u003e\u003cem\u003eKey recommendations from the pilot workshops\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArea\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecommendations\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGreater use of colours, symbols, and artwork associated with Aboriginal and Torres Strait Islander cultures\u003c/p\u003e \u003cp\u003eImprove sequencing of content to ensure that each topic builds upon the last to promote a holistic understanding\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContent and interactive activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdditional animated features including \u0026lsquo;pop-ups\u0026rsquo;, expandable diagrams, and interactive maps to reduce cognitive load\u003c/p\u003e \u003cp\u003eAdditional community member quotes, especially in video or narrated form to enhance emotional connection\u003c/p\u003e \u003cp\u003eDevelopment of additional case studies and role-specific examples to support applied learning\u003c/p\u003e \u003cp\u003eSimplification of \u0026lsquo;slides\u0026rsquo; with excessive text, replacing long paragraphs with dot points or visual representations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice insights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnsure the inconsistencies between the Aged Care Quality Standards and providing care to Aboriginal and Torres Strait Islander peoples are reflected upon\u003c/p\u003e \u003cp\u003eHighlight the importance of open communication, listening, and building trust with clients, particularly through yarning and storytelling as both assessment tools and healing practices\u003c/p\u003e \u003cp\u003eRecognising systemic barriers (e.g., fragmented services, lack of service coordination)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Module Refinement and Distribution\u003c/h2\u003e \u003cp\u003eOnce feedback from the development workshops had been integrated into each module, a final review of each module was undertaken by the research team before being uploaded into ACS\u0026rsquo; Learning Management System. Each module was subsequently trialled by the PSC and research team. The name of the training program, \u003cem\u003eWalking Together in Aged Care\u003c/em\u003e, emerged during a PSC meeting. In this discussion, a community member (NW) expressed that her aspiration for the program was to \u0026ldquo;teach aged care workers to walk alongside us within aged care.\u0026rdquo; This articulation reflected both the ethos and the intended objective of the program, grounding the title in the expressed priorities and lived experiences of community members.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Evaluation Interviews\u003c/h2\u003e \u003cp\u003eWe then conducted a preliminary evaluation of the training program. All ACS staff aged 18 years or over, who were involved in the direct care of clients and who had completed the training program were invited to participate in a semi-structured evaluation interview via email invitation from the CEO, following the same processes as the workshop invitation. Informed consent was obtained prior to the interview by verifying participants\u0026rsquo; understanding of the study purpose and involvement. Semi-structured evaluation interviews with ACS staff took place between December 2024 and February 2025. An evaluation interview guide was developed by the research team and PSC. With participant consent, all interviews were audio-recorded and transcribed verbatim by a third-party transcription service. Each participant was offered a copy of their transcript for review. The interview transcripts were de-identified using alpha-numeric codes to preserve the anonymity of participants. Using NVivo V.20, the transcripts were thematically analysed following Braun and Clarke\u0026rsquo;s approach (JZ, AP) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Key themes were refined before being endorsed by the CIC.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Implementation\u003c/h2\u003e \u003cp\u003eThe training program, titled \u003cem\u003eWalking Together in Aged Care\u003c/em\u003e, was launched organisation-wide in November 2024. The CEO encouraged all staff to complete the training program as part of their regular employment duties. As of August 2025, \u003cem\u003en\u0026thinsp;=\u0026thinsp;125\u003c/em\u003e ACS staff had commenced the \u003cem\u003eWalking Together in Aged Care\u003c/em\u003e training program. This level of engagement highlights both ACS\u0026rsquo; commitment to workforce development and the relevance of the training content to the needs and priorities of ACS.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Evaluation Interviews\u003c/h2\u003e \u003cp\u003eIn total, six of 20 participants invited completed an evaluation interview. This included \u003cem\u003e4\u003c/em\u003e women, \u003cem\u003e2\u003c/em\u003e men, and \u003cem\u003e1\u003c/em\u003e participant who identified as Aboriginal. The median age was 45.5 years. The number of years employed by ACS included less than one year \u003cem\u003e(n\u0026thinsp;=\u0026thinsp;2)\u003c/em\u003e, 1\u0026ndash;2 years \u003cem\u003e(n\u0026thinsp;=\u0026thinsp;2)\u003c/em\u003e, 3\u0026ndash;4 years \u003cem\u003e(n\u0026thinsp;=\u0026thinsp;1)\u003c/em\u003e, and more than 5 years \u003cem\u003e(n\u0026thinsp;=\u0026thinsp;1)\u003c/em\u003e. Work roles included direct care, care coordination and cultural and/or community engagement. Three participants completed the training one week prior to the interview, three weeks prior \u003cem\u003e(n\u0026thinsp;=\u0026thinsp;1)\u003c/em\u003e, and one month prior (\u003cem\u003en\u0026thinsp;=\u0026thinsp;2)\u003c/em\u003e to the interview. The interviews ranged from 25 minutes to 1 hour. From the thematic analysis, four themes were identified: 1) Designed for engagement and accessibility, 2) Navigating technical issues, 3) Learning outcomes and perceived impact, and 4) Considerations for scalability and adaptability. These themes are described in detail below, with additional illustrative quotes presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e to provide further context.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eAdditional illustrative quotes\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIllustrative quote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme 1. \u003cem\u003eDesigned for engagement and accessibility\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; I like the matching [exercises], because that was more interactive. So that\u0026rsquo;s my auditory kinaesthetic side of things \u0026hellip; The mixing and matching where you really got to stop to think about it \u0026hellip; I found that I was learning multiple things at once then (Participant 6)\u003c/p\u003e \u003cp\u003e\u0026bull; The next slide was like a heap of information, which was really good information, which would have been good to have before I got to the questions, because the information, I felt, from the questions was in the next slide after the questions \u0026hellip; I just felt like a times there was information, I didn\u0026rsquo;t feel that it related directly to what you were asking (Participant 5)\u003c/p\u003e \u003cp\u003e\u0026bull; I think the videos were good. I think it's good to hear from Elders (Participant 3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme 2. \u003cem\u003eNavigating technical issues\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; I feel like the user friendliness again in technically, formatting wise. I don\u0026rsquo;t know, maybe it\u0026rsquo;s just ACS \u0026hellip; It wouldn\u0026rsquo;t really work sometimes. So, you kept on going back and forth so it wasn\u0026rsquo;t friendly in that way (Participant 3)\u003c/p\u003e \u003cp\u003e\u0026bull; I guess in the future we\u0026rsquo;ll need to be ready for the glitches and stuff (Participant 2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme 3. \u003cem\u003eLearning outcomes and perceived impact\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; It was an eye-opener, not having been exposed to anything like that before. Some of the information was a little bit confronting, but it sorts of opened my eyes to, you know, what happened \u0026hellip; I could only imagine some of the trauma that\u0026rsquo;s been, you know, felt through the generations. It\u0026rsquo;s made me want to learn more (Participant 4)\u003c/p\u003e \u003cp\u003e\u0026bull; I really enjoyed it. I got a lot out of it, and I thought I knew a lot about First Nation people, but I\u0026rsquo;ve learned so much more\u0026hellip; It\u0026rsquo;s good that you\u0026rsquo;re finally getting courses out there like this because, as I said, I have not in the last twenty years of doing this topic, had anything that\u0026rsquo;s really come directly from the people we\u0026rsquo;re trying to look after (Participant 1)\u003c/p\u003e \u003cp\u003e\u0026bull; I think it's [the training] needed. And I do think that people who provide, services to Indigenous people need more training and I do think there needs to be a lot more understanding to be able to provide services in a way that's culturally appropriate, and that they feel safe and secure enough to talk to you about stuff as well \u0026hellip; So, I do think there is a huge need for the training. Those things would be great for someone who's never worked in an Aboriginal organisation. \u0026hellip; So, you know, it really made an impact for me, and that's why, I guess, I'm very, um, I guess, passionate about seeing something like this (Participant 6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme 4. \u003cem\u003eFuture directions for scaling and adapting the training program\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Everyone in the organisation, and it's not just the people, like, who have contact with the Elders. Like, I still think even, like, the management people up here as well, because they also need to understand, because then they need to understand where, at times, that we're coming from, as to why something needs to be done a certain way, as to why, you know, we can't do it like ABC. We need to go to A and then D and then, you know, like, back to B you know because that's going to work better. So, I think, you know, and I think you should also roll it out to the government (Participant 5)\u003c/p\u003e \u003cp\u003e\u0026bull; I could see you splitting them out and doing some of them individually \u0026hellip; Looking at [each module] in relation to what your staff need and identifying any issues or gaps, and then there might be a gap in relation to one part of that training that you could certainly use \u0026hellip; I was learning so much in that period; I think it was probably hard to digest everything ... And then you\u0026rsquo;re more focused (Participant 1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1. Designed for engagement and accessibility\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants highlighted the flexible, modular structure of the training program as a key strength. The sequential design, with each module building upon the last, was highlighted for its holistic approach to learning. Participants appreciated being able to complete the training program at their own pace, with the ability to pause and return allowing them to balance workplace demands. The mixture of interactive activities (e.g., videos, case studies, and multiple-choice) and written information was positively received, effectively conveying key messages and removing barriers to engagement.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eEach module sort of like fed into the next, which was nice \u0026hellip; And you know, you certainly didn\u0026rsquo;t have to do it all at once and they were small enough, each module, that you could perhaps do a couple and then maybe a couple the next day. And I didn\u0026rsquo;t think there was too much reading. I thought there was just enough to give you a really good idea of \u0026hellip; the message you were trying to get across. I thought it gave you the right amount of information. Some training courses I find don\u0026rsquo;t give you enough \u0026hellip; to give you a holistic picture of what you\u0026rsquo;re trying to do (Participant 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe training was enriched through inclusion of digital content where local Elders described their real-life experiences. This added authenticity, particularly in culturally sensitive areas, and multiple-choice questions were noted for promoting active learning. However, there were calls to expand interactivity further. Additionally, the open-ended strategy-based questions were described as challenging or confusing, particularly when prompts felt vague or overly broad. Participants suggested rewording them to enhance clarity, incorporate role-specific responses, and to ensure that they had received the information required to answer such questions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThey gave a statement, and now it\u0026rsquo;s over to you to write a strategy and you\u0026rsquo;re sort of like a bit lost. Like, what do I write? I feel like there could have been one or two questions and maybe an example, and then okay, that's what they want me to do \u0026hellip; So, it wasn\u0026rsquo;t friendly in terms of what they wanted you to write \u0026hellip; I think you need more of a promoting question rather than a statement (Participant 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2. Navigating technical issues\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants encountered several technological issues when completing the training program which impacted their ability to complete all modules efficiently. Reports of \u0026lsquo;glitches\u0026rsquo;, including blank slides, being unable to progress past certain points, and written responses failing to register within the LMS, prevented progress. Despite efforts to address these glitches, participants noted that the system remained unreliable and difficult to use. However, participants emphasised that these challenges were not a reflection of the training program\u0026rsquo;s design, but instead due to limitations of the training platform used by the organisation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI just found the system a little bit hard to use \u0026hellip; But I worked that out quickly. That\u0026rsquo;s [the technology] something that can certainly be improved. It\u0026rsquo;s just the training system we use \u0026hellip; That was the only thing that frustrated the kajeebies out of me (Participant 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 3. Learning outcomes and perceived impact\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants reported initial positive learning outcomes and found the training program highly valuable and relevant to their roles. For some, it served as a refresher; for others, it opened new areas of understanding and confidence to provide culturally safe care. All however appreciated the opportunity to deepen their knowledge and reflect on their practice.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt did make you think of what we could do as an organisation, to support Elders through everything \u0026hellip; If we\u0026rsquo;re implementing a social support program, we can look at learning from this, how we make it culturally safe and a safe place for Elders to speak if they need to. I think it makes you think how can we do things better. What are we missing? What can we do? (Participant 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThey emphasised the importance of ongoing engagement with the training program to continue expanding their understanding, assessing existing practices and to identify gaps and areas for improvement, and applying their learnings in their work. Key learnings surrounded the needs of Stolen Generation Survivors, grief and loss, and intergenerational trauma, though participants noted a need for additional information on specific cultural groups, Advance Care Planning, and one-on-one interactions. Many shared what they had learned with their colleagues, valuing collective learning and collaboration, and noted that the training helped break down stigma around sensitive topics, and contribute to trust and rapport-building. Ultimately, the program was viewed as a crucial step toward embedding culturally responsive practices in aged care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI do think there needs to be a lot more understanding to be able to provide services in a way that's culturally appropriate, and that they feel safe and secure enough to talk to you about stuff as well, because they need to feel comfortable enough to talk to you. So, I do think there is a huge need for the training (Participant 5)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 4. Future directions for scaling and adapting the training program\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants highlighted key considerations for scaling and adapting the training program beyond its initial implementation. Several noted that similar programs were lacking in, making this training unique and necessary. Participants emphasised that the training would be beneficial for a broad range of staff, not just those in direct care roles, as having a consistent and shared understanding would enhance the quality of care being provided. Reflecting on their clients\u0026rsquo; negative experiences with other organisations, there was strong consensus that the training program be rolled out to all organisations providing services to older Aboriginal and Torres Strait Islander people to address their experiences of racism and the lack of cultural safety. This would help foster respect across the broader sector. Participants not only endorsed its continuation but also advocated for its wider implementation to ensure that more professionals benefit from its insights and practical applications.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think if you\u0026rsquo;re working for an Aboriginal organisation \u0026ndash; it doesn\u0026rsquo;t matter what your role is, you need to have a broad understanding of what it is we do here. I don\u0026rsquo;t care whether you\u0026rsquo;re in finance or you\u0026rsquo;re the janitor, like you need to know, it\u0026rsquo;s across the board. I think it\u0026rsquo;s important if we\u0026rsquo;re all in aged care, this [the training program] should be rolled out to all the aged care providers, because it\u0026rsquo;s specific (Participant 6)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMoreover, participants emphasised the need for additional flexibility in the delivery of the program, highlighting the benefits of incorporating group-based and face-to-face learning alongside digital formats. While the online modules were praised for their accessibility, they were not considered sufficient on their own. Incorporating different delivery modes would provide a richer learning experience where recipients could ask questions in real-time, engage in discussions, and seek clarification on complex topics, and thus foster a sense of shared learning. A blended approach, where organisations begin with digital content before transitioning into face-to-face sessions, would facilitate this.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI would maybe suggest a team environment, because it\u0026rsquo;s always good to have a conversation with people, because someone\u0026rsquo;s got a different experience to yourself, the person on the left of you, to the right of you. I think if you had some of the Elders involved as well, I think that would be good \u0026hellip; If you\u0026rsquo;re in a situation where you can have a conversation with someone, they might be able to offer a bit more of an explanation to better understand the situation (Participant 4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eDeveloped through a co-design process with ACS, \u003cem\u003eWalking Together in Aged Care\u003c/em\u003e responds directly to the urgent need for comprehensive, tailored and culturally grounded workforce development strategies to promote positive aged care outcomes for Aboriginal and Torres Strait Islander peoples [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The training program was purposefully designed to equip the aged care workforce with the knowledge, skills and confidence to deliver care that is trauma-informed, culturally safe, and responsive to the health, wellbeing and cultural needs of Aboriginal and Torres Strait Islander peoples. While much of the current aged care training landscape remains oriented towards task-based competencies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], this training program enhances this by incorporating the relational, ethical, and cultural dimensions of care \u0026ndash; dimensions which are often undervalued but are central to the health and wellbeing of Aboriginal and Torres Strait Islander peoples. In doing so, it responds to the call from the \u003cem\u003eRoyal Commission into Aged Care Quality and Safety\u003c/em\u003e for a fundamental shift in how the workforce is supported to provide care that upholds dignity, rights and cultural identities [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInterviews indicate that \u003cem\u003eWalking Together in Aged Care\u003c/em\u003e has contributed to increased workforce confidence in providing culturally safe and responsive care. Participants reported that the training program would support them in building trust and rapport with their clients, in critical reflection, and promote learning in priority areas identified by Aboriginal and Torres Strait Islander peoples, including ageing well, social and emotional wellbeing and grief and loss. Central to this success was the flexible, modular and self-paced delivery, and the range of interactive activities which accommodated varying literacy levels and learning styles. Such delivery methods may address key factors associated with workforce retention, including burnout, which are acute in resource-constrained settings [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, there was strong endorsement that the training program be made available across the sector, reaching not only frontline workers, but also those in ancillary, administrative and management roles. This highlights that culturally safe care is not the sole responsibility of frontline workers but rather depends on the capacity of the entire service system to respond in relational, ethical and culturally informed ways \u0026ndash; with each point of interaction contributing to care experiences and outcomes. This extends to those working in policy, commissioning and regulatory roles, who may shape the conditions under which aged care is being delivered [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Too often, aged care workers are required to adopt a model of care ill-suited to Aboriginal and Torres Strait Islander peoples which places additional burden on the workforce [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. As identified in this study, \u003cem\u003eWalking Together in Aged Care\u003c/em\u003e presents a critical mechanism to promote a shared understanding between workforce employed across all levels of the aged care sector, which may lead to practice and policy decisions that better reflect the needs of Aboriginal and Torres Strait Islander peoples.\u003c/p\u003e \u003cp\u003eParticipant feedback highlighted a clear need for a blended modalities of online content with face-to-face learning. This aligns with the broader consensus that while digital learning can expand reach and accessibility, it is through interpersonal connection and dialogue that deeper, practice-level transformations are most effectively achieved [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. At the same time, online training remains a practical and viable option for workforce and even more so for those in geographically isolated areas. The primarily online delivery of this training program highlighted persistent inequities in digital infrastructure across the sector, including access to adequate technology, stable internet and IT support, which disproportionately impact underfunded and geographically isolated services [\u003cspan additionalcitationids=\"CR39 CR40\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Therefore, as aged care reforms increasingly prioritise workforce training and development, they must address not only what is delivered, but how training across regions can be equitably accessed and sustained.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWalking Together in Aged Care\u003c/em\u003e contributes significantly to the broader aim of building a workforce with the knowledge, skills and confidence to support the growing number of Aboriginal and Torres Strait Islander peoples accessing aged care [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] which now includes Stolen Generation Survivors who may require additional healthy ageing and care considerations, including trauma-informed supports [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. It also responds to the reality that health and aged care is delivered across both Aboriginal-specific and mainstream services, necessitating a consistent standard of care irrespective of service context [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Further, considering the ongoing underrepresentation of Aboriginal and Torres Strait Islander peoples employed across the aged care sector, the training program affirms the critical role of the non-Indigenous workforce in advancing culturally safe care. Rather than positioning cultural safety as the sole responsibility of Aboriginal and Torres Strait Islander workers, the training supports a shared workforce responsibility and ensures non-Indigenous staff are equipped [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBroadly, this study affirms the value of co-design as a powerful and necessary strategy to navigate the complex terrain of innovation across the aged care sector, where systemic constraints and service pressures can often inhibit the adoption of new practices [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Rather than imposing external solutions, our co-design approach which closely aligned with the key principles of co-design in Aboriginal and Torres Strait Islander health allowed for innovation to emerge from within the sector, tailored to context, guided by community and informed by practice [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The value of this approach is well established in the literature, which underscores training programs are more likely to be adopted, effective, and sustained when they reflect the values and practices of those they are intended to serve [\u003cspan additionalcitationids=\"CR46\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Strengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study has several key strengths. Our partnership with ACS, the major provider of aged care for Aboriginal and Torres Strait Islander peoples in South Australia, ensured strong alignment with community-identified priorities and existing workforce development strategies. This partnership facilitated a structured framework for meaningful engagement and implementation with a broad range of staff, ensuring contextual relevance and practical applicability of the training program. Moreover, the design of the training program was largely informed by prior research undertaken by Wardliparingga. This evidence base provided a strong foundation for identifying training needs in addition to core components of ageing well and aged care for community members in South Australia. While only a preliminary evaluation of the pilot program was undertaken, early implementation data such as this is important in understanding the initial reach of the program and provides a foundation for future evaluation of its impact and scalability across the broader aged care sector. While efforts were made to engage widely with the remote workforce, time and resourcing constraints restricted the depth and breadth of engagement within remote regions. Additionally, while the survey component extended beyond ACS, the remainder of the study activities were undertaken exclusively with ACS. This strengthened the training programs\u0026rsquo; localised focus but limits its broader generalisability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Future Directions\u003c/h2\u003e \u003cp\u003eBuilding on the outcomes of this study, future phases will focus on scaling the training program to a broader range of organisations and service settings to ensure relevancy and applicability. A key focus will be ongoing engagement with Aboriginal and Torres Strait Islander communities in South Australia in the development of videos and case studies, and with the remote workforce who have distinct cultural, logistical and service delivery considerations that require sustained engagement strategies. These contributions are essential to ensuring that the training program remains grounded in lived experience and reflects workforce needs in local area contexts. To promote long-term sustainability, integration of the training program into accredited training and formal qualifications will be explored in collaboration with the Vocational Education and Training (VET) sector, Registered Training Organisations (RTOs), and peak training bodies.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eAs health and aged care systems contend with population ageing, increasing care demands, and ongoing reforms, there is an urgent need to develop training programs that reflect the perspectives of both those receiving and delivering care. This study demonstrates that meaningful workforce development, designed by, with and for Aboriginal and Torres Strait Islander communities and the aged care workforce, is an essential component to achieving equity in aged care. The \u003cem\u003eWalking Together in Aged Care\u003c/em\u003e training program presents a compelling model of locally grounded, culturally informed training which may help address systemic barriers, foster culturally safe care, and respond to the complex realities faced by clients and staff alike. In this context, training must be recognised not simply as professional development, but as a critical lever for health equity and an act of systemic repair and responsibility. Embedding community and workforce informed training within national workforce strategies will be essential to achieving the goals of aged care reforms. Programs like this may offer a clear path forward \u0026ndash; grounded in self-determination, community knowledge, and a commitment to equitable care.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e Ethical approval to conduct this study was granted by the South Australian Aboriginal Health Research Ethics Committee (AHREC) (#04-23-1084). All participants provided written informed consent. All research procedures involving human participants were conducted in accordance with the principles of the Declaration of Helsinki and with relevant national ethical guidelines for research involving Aboriginal and Torres Strait Islander peoples.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e This work was supported by Aged Care Research and Industry Innovation Australia (ARIIA) (#GA00075) and Medical Research Futures Fund (MRFF) (GNT: 2024389). OP was supported by a National Health and Medical Research Investigator Grant (GNT: 2026852).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJZ: Conceptualisation; Methodology; Formal Analysis; Investigation; Resources; Writing \u0026ndash; Original Draft; Writing \u0026ndash; Review and Editing; Visualization; Supervision; Project Administration; Funding acquisition. TI: Conceptualisation; Investigation; Writing \u0026ndash; Review and Editing. AD: Conceptualisation; Methodology; Writing \u0026ndash; Review and Editing; Supervision; Funding acquisition. GA: Conceptualisation; Writing \u0026ndash; Review and Editing; Supervision; Funding acquisition. CD: Formal analysis; Writing \u0026ndash; Review and Editing; Project administration. NW: Formal analysis; Writing \u0026ndash; Review and Editing. JM: Formal analysis; Writing \u0026ndash; Review and Editing. AP: Conceptualisation; Methodology; Formal Analysis; Investigation; Resources; Supervision; Project Administration; Funding acquisition; Writing \u0026ndash; Review and Editing. OP: Conceptualisation; Methodology; Formal Analysis; Investigation; Resources; Supervision; Project Administration; Funding acquisition; Writing \u0026ndash; Review and Editing\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to acknowledge and pay their respects to the Traditional Owners of the lands on which this research was conducted. We pay our respects to Elders past, present and future. We extend our gratitude to the study participants for sharing their experiences and views, our partnership with ACS, and the PSC who provided governance and advice.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData from this study are not available due to the sensitive nature of the content discussed.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAustralian Institute of Health and Welfare. 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Int Nurs Rev. 2021;68(1):49\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJamieson SK et al. A Community-Led Approach to Understanding How Service Providers Can Support 'Ageing well' for Older Aboriginal People in Australia. J Gerontol Soc Work, 2025: pp. 1\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThompson SC et al. Engaging Health and Aged Care Workers in Rural and Remote Australia Around Factors Impacting Their Access to and Participation in Dementia Training. Geriatr (Basel), 2025. 10(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePearson LH. C., Partners in health to eLearning module development in rural and remote Western Australia. National Rural Health Alliance; 2019. pp. 1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStack J. \u003cem\u003eOpinion: Why aged care can't afford eLearning\u003c/em\u003e. 2024 16 May 2025]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://insideageing.com.au/opinion-why-aged-care-cant-afford-elearning/\u003c/span\u003e\u003cspan address=\"https://insideageing.com.au/opinion-why-aged-care-cant-afford-elearning/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Aboriginal Community Controlled Health Organisation, Indigenous Digital Inclusion Plan - Discussion Paper. 2021, National Aboriginal Community Controlled Health Organisation,. pp. 1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFoundation H. Are you waiting for us to die?' The unfinished business of Bringing Them Home. Healing Foundation; 2025. pp. 1\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZagler J, Yu N, Cleland A. \u003cem\u003eThe system allows for it to happen: the experiences of human service workers in engaging with Aboriginal participants of the National Disability Insurance Scheme.\u003c/em\u003e Disabil Rehabil, 2024: pp. 1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWindle A, et al. Factors that influence the implementation of innovation in aged care: a scoping review. JBI Evid Implement; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDopp AR, et al. Integrating implementation and user-centred design strategies to enhance the impact of health services: protocol from a concept mapping study. Health Res Policy Syst. 2019;17(1):1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJanamian T, et al. Co-creating education and training programs that build workforce capacity to support the implementation of integrated health care initiatives. Med J Aust. 2022;216(Suppl 10):S9\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Gemert-Pijnen JE, et al. A holistic framework to improve the uptake and impact of eHealth technologies. J Med Internet Res. 2011;13(4):e111.\u003c/span\u003e\u003c/li\u003e\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-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"aged care, workforce, training, co-design, Aboriginal and Torres Strait Islander","lastPublishedDoi":"10.21203/rs.3.rs-8437626/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8437626/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePrior research has highlighted the critical need for targeted training to ensure the aged care workforce are equipped to respond effectively to the diverse and complex needs of Aboriginal and Torres Strait Islander peoples receiving aged care. Therefore, this study aimed to co-design, implement and evaluate a training program to strengthen the capacity of aged care workers to deliver culturally safe and responsive care to Aboriginal and Torres Strait Islander peoples.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe training program was developed through a mixed-method approach, undertaken using a community-based research framework where researchers worked in partnership with an Aboriginal community-controlled aged care organisation. This process included a literature review and survey to inform program content, followed by development workshops, an implementation pilot, and evaluation interviews with the aged care workforce across metropolitan, regional, and remote South Australia in 2024.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA training program, titled \u003cem\u003eWalking Together in Aged Care\u003c/em\u003e, was co-designed and centres the health, wellbeing and cultural needs of Aboriginal and Torres Strait Islander people receiving aged care and is relevant to workforce needs. Evaluation interviews revealed high course acceptability, key learnings, and considerations for scalability and applicability across diverse aged care settings.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e \u003cem\u003eWalking Together in Aged Care\u003c/em\u003e contributes significantly to the broader aim of addressing a lack of appropriate training programs for the aged care workforce delivering care to Aboriginal and Torres Strait Islander peoples.\u003c/p\u003e","manuscriptTitle":"‘Walking Together in Aged Care’: The co-design and evaluation of an Aboriginal and Torres Strait Islander aged care training program","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-21 06:27:22","doi":"10.21203/rs.3.rs-8437626/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-29T06:52:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-27T07:39:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"130025533836477609596866777791080220048","date":"2026-04-13T00:43:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-15T07:47:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-24T22:23:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"56017165837198600907923817365691196873","date":"2026-02-24T21:09:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"303776549740152922481426357276705503805","date":"2026-02-22T22:44:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177886206958288253245283279106992302423","date":"2026-01-21T03:36:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-19T00:42:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-11T20:36:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-06T06:38:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-05T02:46:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2026-01-05T02:41:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0cc08828-b461-4f39-b427-c9a47e254962","owner":[],"postedDate":"January 21st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-01T22:09:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-21 06:27:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8437626","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8437626","identity":"rs-8437626","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}