Table 3.

Process of formulating meanings and clusters for the Aboriginal and Torres Strait Islander patients.

Location of significant statement	Statement (quotes)	Formulated meaning	Theme Clusters	Theme [T]
1063 – Page 4	“It helped me with peace of mind because I got someone. That’s what I mean someone needs to be there with them (patients) not to be there on their own.”	Physical presence, assurance	ATSIHLOs support; they are the “brokers” between patients and health professionals	Role of ATSIHLOs [T1]
R4 – Page 13	“Well they were the pawns between the system and us. The system and its rigid protocols or policies and the Liaison Officer who got them to bend or come to their senses a little bit and then hopefully through that then this person here will climb up the ladder somewhere where policy can change.”	Listen to patient needs, links the patient to healthcare system and tries to address these patient needs
2051 – Page 15	“Those stereotypes like even over minor things if you’re stereotype people get out of the game. Don’t come near an Aboriginal person because you’ll offend them and upset them in ways you will not understand and that was my because like I had a lot of benefits and disadvantages like I was too white for some relatives and I’m too dark for white people. So I experienced both spectrums and I know well just for myself.”	Stereotypes: too white to be black and too dark to be white	Psychological factors causing pain: stereotyping, discrimination and stigma	Emotional pain [T2]
R5- Page 18	‘Like I know that like some Indigenous patients are very or can be very self-righteous, absorbed and I really, really love the patients that go “Oh well you’re discriminating against me because I’m Aboriginal” and I turn around and go: “Well you’ve spoken to the wrong person”. And then they look at me and I go: “Well you’re looking at the XX…. Aboriginal and Torres Strait Islander of the year”.’	Discrimination: too white to be black
R6- Page 18	‘You know what I say to them? “Honey you barked up the wrong tree because I’m the only white blackfella that you’re going to meet today”. Because my own people say “Oh you’re too white. You’re too white”. That took so much out of me growing up. Even when I got put in homes and everything else like that. …	Discrimination: too white to be black
R3 – Page 16	It is for your own people to shun you.’	Discrimination: too white to be black
R3 – Page 19	‘Oh you know, “These white fellas that think they’re black”.’	Discrimination for being Aboriginal
	‘When the aged-care guy rang up to say that he was coming out to see what help I needed and then we’d been chatting away about you know, fine, and then he said, “Hang on, you’re not old enough”. And I said, “Yes I am, I’m Aboriginal”, straight away he goes “Right, how many people live in the house? Anyone fresh out of jail? Is there any guns? Is there any vicious …”.’
R5 – Page 21	‘Straight in to the judgement. You know straight in to the whole well they look at you, they look at me and go “Oh well you must be a smoker and drinker”.’	Discrimination for being Aboriginal
R6 – page 22	“So the stigma that surrounds Aboriginal people, Aboriginal people that have had something go wrong in their past or anything is absolutely atrocious. And these people should be taught while they’re in university that you have to look beyond that, you have to look at the person, you have to look at that person now not their past. Yes, have a look at their medical past, get to know that person, ask your questions, do it in a caring one-on-one level of emotional connection rather than a clinical piece of paper and a pen.”	Discrimination for being Aboriginal
R5 – Page 7	‘“Oh well you’re just drug-seeking”.’	Stigma – drug seeker
R3 – Page 8	‘“You’re a doctor shopper.”’	Stigma – drug seeker
2064 – Pages 3–4	‘I got the vibe that she thought that I was abusing drugs the way she approached me. So I walked out of the clinic, they all came chasing after me and they said “What’s wrong? What’s wrong”? And I said “This is where the communication breaks down and you are jumping to conclusions without actually approaching me in a proper mannered way”. So and I explained to that person I said “Look there are drug abusers with medication but you had a chance to actually ring my doctor’s office or whatever the medical centre that I’d been going to. Not trying to”….yeah she was trying to gouge out something that she thought that I was trying to just abuse the drugs. Which actually made me really, it makes you really bad and sad and emotional and all those things. And then with me I had, I made sure I put in a full report so those things don't happen again to other patients. But you’ll get, often those things will happen, especially when you’re on pain drugs.’	Stigma – drug seeker
R5 – Page 9	‘I think it’s the fact that usually you get to, patients get to desperation stages with pain and patients just want to be believed.’	Want to be believed/validated
1108 – Page 1	‘People like to call you a drug fisher or a hypochondriac that your pain couldn't possibly be that bad. And you’re still able to do things with your children day to day things. Well they need to be done and yes I am in that much pain.’	Stigma – drug seeker and not believed
2067 – Page 1	‘They just that was just the way the conversation was headed. And I mean they weren’t nasty about it or anything but I just came away from it feeling left out in the cold I guess.’	Feeling isolated and alone, discharged per protocol not because patient was well
R6 – Page 22	‘And I really hate when they say “On a scale of one to ten what’s your pain like?” I said, “Honey for you city people mine’s a nineteen”. I said “I was born country, I’ll handle it til it hits thirty, thanks”. The scale of one to ten is just bulls*** because you cannot put a scale on pain because some people mask that pain better than others.’	Pain measures do not appear to assess appropriately pain for Aboriginal and Torres Strait Islander patients	Scales do not measure patient pain	Failure in pain measure [T3]
1104 – Page 2	‘I sometimes feel that they don't understand where I'm coming from with the pain. I feel like, sometimes I feel like they’ve just got me in that category where everybody suffers the same pain from an injury.’	My pain is not in a category	No recognition of individual experience of pain
2064 – Page 4	‘They were trying to get information out of you but when you were in pain and you come up with the wrong answer then she was punishing me for that and then saying “Well what’s the story? You’re not getting your story straight”.’	High levels of pain interfere in the ability to think clearly and describe or measure pain	Ability to thinking is compromised affecting response
2067 – Page 2	‘…places and appointments and try and keep them all straight in my head. And on a calendar and all the rest of it and I'm not good with those sorts of things anyway. But when I'm feeling you know when my pain levels are particularly high and it interferes with my ability to think clearly.’
1054 – Page 1	‘Well I …I have found myself quite a good doctor at the moment. He is Sri Lankan by birth, he’s got a Russian wife, he’s very culturally aware of different cultures. And he respects my cultures and my beliefs.	HP respects patients’ culture and beliefs	Enablers of effective communication: Respect	Positive communication experiences [T4]
	He doesn’t push …he doesn’t push the hard line drugs on me.
	He’s respectful and he will say to try herbs and vitamins before all different sort of things before he pushes the hard line drugs on me and to me.’	HP offers alternative treatments	Trust
R6 – Page 14	‘Then don’t be clinical. There’s no need to be clinical, if you’ve got fifteen minutes with this person and you’re going through these questions and everything else like that pull up. Okay here’s the first question, “Oh you know Aunty how are you feeling? I’ve got a couple of questions here, we might just go through them a little bit slow about what’s happening” and you know make conversation as well as get the questions answered. And that person’s going to think, “Shit they’re taking time”. It doesn’t have to be an hour, it’s how you put the question across, it’s how you communicate with that person while you’re doing what you need to do.’	Take the time, is not clinical, get to know the patient	Showing interest Offering support Working together
1054 – Page 2	‘Well mainly my current psychologist has asked if I would like to see an Aboriginal counsellor. Instead of me being comfortable with just an ordinary so called Caucasian counsellor. They’ve actually suggested if I wanted to that I could see an Indigenous counsellor, Indigenous psychologist. Which that actually blew me away when they offered me that. I said I didn't mind either way, anybody.	Health professional offers Indigenous support services
	Yeah. And they asked if I would be more comfortable with an Indigenous sort of psychologist or counsellor. Which I think that totally blew me away.’
2064 – page 5	‘Sometimes in the big hospital it’s always good to ask would you like me to call an Aboriginal liaison officer to sit in with or like to give them information that says “Look if you feel uncomfortable or felt that this didn't go too well you can contact the Aboriginal liaison officer”. And I think that’s the other thing that they should be doing is getting the patients the option of that.’	Health professional offers Indigenous support services
1063 – Page 2	‘I have a doctor and I explained to him what was going on and there’s not many doctors who would do that. And I said to him I said no doctor is listening to me but I need to know that I can bend and stretch and actually do things with my grandchildren I couldn’t even do any of that until he listened to me.’	Listen to me
1108 – Page 3	‘Yeah…my doctor was good. She listens to everything that I'm saying and it’s because she listens that I’ve avoided a lumbar puncture in so long. And did she do anything in particular that you know she’s listening to you? No, it’s basic you know body language, eye contact	Listen to me, body language, eye contact
1062 – Page 2	I don't think it’s just me being Aboriginal I think it would be a lot of Aboriginals would have the same anxiety with people not listening to them.’
2071 – Page 9	‘He (doctor) was absolutely brilliant he’d sit down and discuss everything. And then when he found out what it was he’d sit down and discuss it with me and my partner, like my wife and you know discuss this is what’s going to happen. You know it could come, it could like it’s there it could go away you know it may stick with you for the rest of your life.’	Sit down, explained and discussed what is going to happen
1104 – Page 4	‘But the one-on-one with Doctor XX, it was brilliant, it was amazing. Because she just sat there and listened and we talked. Yeah you know she pulled up a chair, she wasn’t there on her computer going, “All right Mister XX has had blah, blah, blah” that was it. You know she pulled up a chair, sat down, we had a yarn. The other doctors like the young doctors stayed with her and we just yarned about everything. She wanted to know more about our culture so I taught her. And so she said that opened a door up for her.’	Sit down and had a yarn, showed interest in knowing more about patients’ culture
1063 – Page 2	‘Yeah when I see the regular doctor (XX) because I was just saying she’s very good, very empathetic, understanding, she understands probably the best out of the lot. She’s been really good.’	Empathetic, understanding
2064 – Page 2	‘Well when I go see my doctor it takes me time to see if I really trust him or not. But when he’d sat down and spoken to me and listened to me that’s when I knew I could trust him with any problem with my back.’	Building trust
1063 – Page 3	‘With me is the, I always return to resources. So if you’ve got the right resources like you’ve got them on a piece of paper sent to you via email then if you’re having problems you can always go back and have a look at it again. Or you can show a family member or whoever, you might be able to show your GP what you’re doing. So that communication link, that’s one of the best things.’	Resources can help the patient re-visit information. Helps to explain to the family
	‘See it works both ways when it comes to the patient they’ve got to learn that it’s not going to be finished overnight it takes time. Especially the doctor you’ve got to let him know maybe a month’s time I don’t know I cannot promise you.’	Collaboration & understanding
1054 – Page 3	‘Oh well one doctor that I was seeing was throwing pills at my issues. And one time during a consultation he took a private mobile call, a private call on his mobile and just had a talk to the person on the other end for five minutes with me sitting in the chair twiddling my thumbs so to speak. He was just totally disrespectful and I haven’t seen him since.’	Disregarding the patient	Barriers to effective communication: Repeating stories Multiple doctors No communication between team members No consideration of the understanding of patients	Negative communication experience [T5]
1062 – Page 3	‘Well okay a couple of the doctors I’ve just walked in there and I said you know “I need my scripts filled”. And that’s it they just fill them and you know when you’re getting a hundred and twenty milligrams of OxyContin you know they’re not even asking questions. Like they say “What’s it for”? Oh “Pain” and that’s it they’re just quite happy just to write it out, write out any prescription drug for you.	Are not interested in your health, just to give prescriptions
1104 – Page 4	They’re the only two doctors that I’ve had that have showed any interest in my health at all.’	Regular doctors vs. temporary, they don’t know you, and don’t provide the same care
	‘Yeah I’d say yes you can know the difference. Someone that I see regularly there compared to like a temp, there’s a difference. But I guess in all fairness they don't know me, they’re just there filling in, they wouldn't know my history as well. So I guess that’s probably why.’
R5 – Page 4	‘And you know a lot of Indigenous people and Aboriginal people the way they get spoken to and it’s “Blah, blah, blah” (talking very quickly) and you only hear, you know especially elderly and I’m looking at my mum. She only, you know unless you have her attention you only get, she only gets parts of the information.’	No sensitivity to identify patient understanding, sending out the message, no concern about the understanding of the patient
R5 – Page 4	‘It actually looks at the, like looking at the patient, all of the patient’s needs and we find that patients, the teams don’t talk. And the teams don’t read the other teams notes half the time and it … you know like it’s, you know when you have them saying opposite things like the patient gets confused.’	Healthcare team does not talk to each other
R3 – Page 6	‘Well I had an experience with a rheumatologist when I felt like I wasn’t in the room. I felt like you know I was totally ignored as a person, as a patient and she didn’t … Yeah I was really shocked.’	Ignored as a person
R5 – Page 7	‘And it gets really frustrating because literally you come down to the pain clinic here, your first one and it’s a two-hour face-to-face and they go through everything, they’ve documented everything, you know they’ve got all of your notes and everything like that. And then you see the same doctor and then you’ve got an intern or someone like that is the next one to see you and they go… then you have to go back over.’	Frustration- telling their medical history all over again
2064 – Page 1	‘Because at the end of the day I think everyone wants to know what the hell is going on with your body even if they can try and find other words to use than those big medical ones. Try and cut it down and make it simple but understandable.’	Health literacy, medical jargons and understanding
2062 – Page 6	‘To me to go to the root of the things, if we can get more Indigenous nurses and doctors and you know and like the hard things. In our way, we speak to one another all being more sensitive culturally to how you know like that’s why a lot of us probably die and stuff because we’re too ashamed to go to the doctors.’	Need for more Indigenous staff to access care to overcome shame	Lack of understanding of historical factors, cultural responsibilities, customs and protocols	Factors affecting access to care [T6]
2062 – Page 6	‘Yeah and see when I go to the Indigenous I tell all my doctors about they’ve got a female there for female health because you know what I mean? …	Access to care and cultural protocols, men’s and women’s business
	And if you go, “I’m sorry but you’ve got to go and see a man” well a lot of them won’t go.’
2071 – Page 4	‘The hospital itself doesn’t understand our culture. Whereas you know like I get put in a room you know with three women. That can’t happen. And I say to them, “I can’t be in here hey, it’s not fair. I don’t want to be in here”. Or they put you in with two white fellas and a little Murri girl in the corner and again I don’t want to be in this room. You know they’ve got to understand our culture.’
2062 – Page 6	‘Yeah so maybe when they’re coming through the universities and they’re at TAFE and that maybe they need to be taught how to be sensitive to Indigenous culture. I mean I don’t know what happens when you train to be a doctor and how to treat different generations you know? Like a seventy year old Aboriginal woman with someone who’s my daughter’s in her thirties you know who didn’t grow up on a mission or you know wasn’t treated … You know what I mean?’	Historical factors affecting access to care
2051 – Page 10	‘And being Indigenous your guard’s up already. And then if you’ve been an Indigenous person brought up through institutionalisation then you’re a different fort again.’
2064 – Page 5–6	‘Now after all the conferences that I’ve been to it is probably a mixture of people that say why do we have to tick that box? So there’s sort of like an issue with that as well why they…and then some people feel if I tick that Aboriginality box then they’re just going to not give me the best care because I'm Aboriginal.’	Fear; not identifying out of fear the patient would not have the best care
2073 – Page 2	‘Look I mean can I tell you, when I first, about my transplant, I was too scared to say I was a blackfella and the reason was, was because I thought I would never get a transplant and that’s how I felt. Because I just felt you know they’re not going to worry about us.
	And I’m not the only one, I mean a lot of our mob’s gone through it and a lot of your ancestors would have too. So you know it’s not easy and then so I thought, “If I don’t tell them I’m a blackfella I might have a transplant and then get a chance”.
	Yeah I honestly thought they’d treat me differently. But I have to admit they didn’t. The unit as far as I was concerned didn’t care if I was black, green, purple or white.