Effective communication training to support person- and whānau-centred care: what is needed and why isn’t it happening?

Studies show that better communication improves health outcomes, safety and equity, while reducing costs.^1,2 Conversely, communication issues contribute to 80% of patient harm events.³ Health Quality & Safety Commission Te Tāhū Hauora’s recent national patient experience survey shows that Māori rate their communication with healthcare providers lower than other ethnic groups, including feeling uncomfortable asking questions.⁴ This hampers shared decision-making and affects health outcomes and equity. Māori still experience poorer health outcomes and shorter life expectancy compared to other New Zealanders.⁵

Patient-centred care focusses on respecting individual preferences and ensuring that clinical decisions align with patients’ values. It is a partnership between practitioners, patients and their families, empowering them with the education and support needed for informed decision-making.⁶ For this report, we use the term “person- and whānau-centred care” (PWCC), which emphasises the importance of recognising the whole person, not just their symptoms or disease, and the role of whānau in Māori health and decision-making^7,8 and of family in Pacific people’s health⁹. PWCC is central to the 2022 Te Pae Tata Interim New Zealand Health Plan and is supported by the Health and Disability Commissioner’s regulations, which protect patient rights, including the right to respectful, informed care and shared decision-making.^10,11

People possess a unique understanding of the impacts of their current health and their future functional needs, which is vital to the clinical decision-making process.¹³ Effective communication is therefore essential to PWCC, ensuring a two-way sharing of information that explores the patient’s values and preferences and supports people and whānau to make decisions based on these.^13,14

In 2020, the leading causes of death in New Zealand were cancers, ischaemic heart disease, stroke and chronic lower respiratory diseases.¹⁵ These conditions are largely modifiable, but effective prevention requires a health system that actively involves patients and their whānau in decision-making.¹⁶ This approach depends on health professionals’ attitudes, behaviours and their ability to support behaviour change through PWCC.¹⁶ While clinician bias and inherent stereotyping of patients can contribute to poorer quality of care for some, quality of care is also reliant on a system that supports behaviour change: recognising that social determinants also have significant impact on health outcomes.¹⁷

One challenge to PWCC is the level of health literacy in New Zealand, which the World Health Organization defines as the ability to access, understand and use health information to promote well-being.^3,5,13 Health literacy varies depending on the situation, and low health literacy is linked to poorer health outcomes, particularly among Māori.^18,19,20 Despite tools to improve health literacy and communication, the implementation of these tools in clinical practice remains inconsistent.⁵ Healthcare professionals often lack adequate training in communication skills that support PWCC and shared decision-making, including plain language to support health literacy.⁵ While some education exists, it is often insufficient or not transferred effectively into practice.^5,13,21,22 Factors such as time constraints, tool familiarity and the de-prioritisation of communication training contribute to this issue.²³

Simulation-based education is widely used in healthcare, generally including reflection or feedback. Practice and supportive feedback are key to developing skills, with feedback being most effective right after a learning event.^24,25 At Health New Zealand – Te Whatu Ora (HNZ), beyond basic graded clinical escalation training, there is often no mandated communication education, despite known risks to patient safety and health equity. Clinical demands often hinder participation in any training, indicating the need for accessible, motivating and effective education strategies. This places the onus on teaching and learning in the workplace. Clinical teachers themselves identify time as a key barrier to coaching in the workplace.²⁶ The effectiveness of the current apprenticeship model of clinical education has been brought into question.²⁷

Artificial intelligence (AI) shows promise in healthcare communication training by offering cost-effective, time-efficient and accessible learning tools.²⁸ Evidence-based virtual patients can safely help learners build communication skills, while supporting development in person-centred care and shared decision-making.^29,30 AI models have the potential to provide a more accessible learning platform that provides clinician learners with feedback and support to grow their capabilities in PWCC and shared decision-making.

Methods

This project was a quality improvement project initiated in 2024 with staff from HNZ and Te Herenga Waka—Victoria University of Wellington on the project team. Research ethics approval was granted by the Human Ethics Committee of Victoria University of Wellington (#31569). The project was funded via Te Titoki Mataora Rapid Acceleration Programme (RAP)1 funding. The project team included consumers, clinicians, the HNZ New Technology and Innovation Manager, a health literacy researcher, AI researchers and representatives from Microsoft.

We took a mixed-method co-design approach utilising a clinician survey and focus groups with consumers and clinicians. We enrolled a non-clinical patient navigator alongside four consumers from the HNZ Consumer Engagement Group who represented Māori, Pacific, older adult, youth, rainbow and disability groups. They engaged in a structured group interview utilising an appreciative enquiry approach. An analysis was completed by two of the clinical project team members and the outputs were then reviewed and endorsed by the consumers themselves.

An anonymous clinician survey was sent to all clinical staff via the chiefs of medicine, nursing, and allied professions; education teams; and senior nursing groups. This gave us a degree of confidence that we were considering all views of the problem we had identified in the literature as they applied to our context, and the desirable features of a potential learning solution.

Twelve clinicians with particular interest in the project, or skills and interest in clinical communication education, were invited to participate in a focus group. Three of the consumers and six of the project team members also attended. With representation from nursing, medicine and allied professions, we facilitated a structured presentation of the data gathered via the consumer focus group and the clinician survey and used the session to further understand and discuss the topic. An analysis was completed by two of the clinical project team members and the outputs were then reviewed and endorsed by the clinicians who attended the focus group.

Results

Consumer respondents

The consumers were asked to describe “good” communication in health interactions with clinicians. Scenarios were used, and they reflected on their own experiences. The appreciative inquiry approach taken provided qualitative data to help guide the learning solution design. In particular, cultural safety, the language and words used, and the need for individualised approaches to communication were highlighted. The focus group outputs were categorised and supported the findings from the literature as outlined below.

1.      Communication is individualised: Each person’s communication needs depend on their values, beliefs and emotional state (e.g., feeling unwell, stressed or in pain).

2.      Building connection is important: There is no single communication method that works for everyone. Building a personal connection is crucial for encouraging questions, aiding understanding and supporting shared decision-making.

3.      Clear language is essential: Many people still struggle with medical language. Using simple, accessible terms, such as those recommended by the Health Literacy Universal Precautions Toolkit, can help improve communication.

4.      Empowerment to ask questions: People want to feel comfortable asking questions and accessing the information they need without feeling judged or uninformed.

5.      Cultural sensitivity: Recognise and respect cultural differences in communication styles and expectations.

6.      Power dynamics in healthcare: The power imbalance between clinicians and patients is especially significant in cultures where respect for authority is emphasised. In such contexts, involving patients and their families in decision-making may require working within existing hierarchical structures.

7.      Transparency about health information: Being open about diagnoses, prognosis and treatment options is important, but the approach to delivering this information should be tailored to each individual’s needs.

When the potential use of AI to coach and provide feedback on communication to clinicians was discussed, concerns were raised about the realism of AI and whether it could truly provide a consumer’s perspective. However, if this concern could be allayed, and given the gap in learning opportunities identified in the literature, the group felt there was a potential benefit to a tool for providing feedback on communication from a PWCC perspective; in particular, a tool to support clinicians to create a connection and develop some understanding of what communication methods will be effective for specific people and whānau, and more importantly establish an environment of trust where patient/whānau are able to communicate what their needs are. Feedback on the language used was also seen as critically important.

Clinician survey respondents

The clinician survey has given the project team a picture of learning experiences from undergraduate level to current-state in our district. This is broken down by key topics below with some consideration of the demographics of the workforce.

Three hundred and twelve clinicians responded to the survey from most disciplines and across all ages and levels of experience. This corresponds to approximately 4% of the current clinical workforce in this district. Of the respondents, 84% were women, 14% were men, 2% preferred not to say and 1 person identified as non-binary. Tables 1–2 and Figure 1 describe the demographics of the respondents. The key survey results are described in Figures 2–8.

View Table 1–3, Figure 1–8.

The self-reported ethnicity of the clinician respondents differs from the ethnic profile of the New Zealand and the Capital, Coast and Hutt Valley (CCHV) population. Unfortunately, due to an inability to access data from the human resources department, we are unable to compare these data to our workforce demographic profile.

Although newer graduates are more regularly receiving this education at undergraduate level, only 44% of senior clinicians reported to have received undergraduate education in relation to PWCC or shared decision-making themselves. Although this relies heavily on memory, it speaks to their perception of being taught and learning these skills at an undergraduate level.

Figures 5–7 indicate that accessing education when it is available is not easy for most (61% of 275 respondents), while learning in the workplace through observation and feedback is challenging.

The survey data present a picture of the current level of confidence and skill, alongside the realities of accessing and implementing learning into practice. Not surprising is the reporting that comfort and confidence with these skills generally improves with time and experience. Interestingly, there were a small number of experienced older clinicians who rated themselves as less comfortable and confident having this type of conversation effectively. It must be noted that confidence does not always equate with competence.

Two hundred and fifty-five (82%) respondents do not regularly have the opportunity to receive feedback from experienced colleagues on their person-centred communication skills with real people in their care or their whānau. Yet 85% of respondents feel that feedback would be useful to improve their skills.

Although 90% of clinicians indicated an openness to using an AI tool that provides feedback on communication skills (Figure 7), concerns were also raised about AI (Table 3). These were categorised into five general domains.

Clinician focus group

The aim of this focus group was to consider, in more depth, the current approach to PWCC education and the options for a new approach. The group concurred with the clinician survey and consumer focus group conclusions. They expanded on these challenges and stated that clinicians are often unaware of their strengths and weaknesses due to a lack of feedback. This hinders their ability to effectively engage with patients and tailor their communication to individual needs and preferences. Access to education to enable this and culturally safe communication is limited. They raised the fact that the apprenticeship model may not be conducive to open and honest feedback due to concerns about vulnerability and power dynamics. The group described positives and negatives to using AI to provide feedback on communication skills that mirrored the findings in the survey (Figure 7 and Table 3).

Discussion

Feedback from consumers has provided further validation of the New Zealand patient survey data and the literature in relation to health literacy and PWCC. Despite there being tools available, and recommended approaches to communication in the clinical setting, the lived experience is that these are not regularly being used or used effectively. Health literacy is not being well supported through the routine use of proven tools. Consumer experience reinforces the literature finding that the application of the Hui Process or other culturally safe and person-centred approaches are not yet fully embedded into practice in this setting.

With continuous practice, including the opportunity to make mistakes, have new experiences and critically receive feedback that supports improvement, we are more likely to build skill and confidence. Access to relevant education that supports integration into practice appears to be a barrier to improving PWCC. Current access to communication-focussed education is limited. Only 17% of survey respondents reported attending communication related training in the last 12 months. Senior clinicians are also not receiving regular feedback; yet, in our current apprenticeship approach, senior clinicians are expected to teach the more junior staff.

The current apprenticeship model—learning in the workplace with feedback—does not appear to be teaching or reinforcing these skills in a meaningful way for all levels. Clinician respondents reinforced the challenge of the apprenticeship model as a way of learning due to concerns about vulnerability.

The differing ethnic profile of our workforce to the New Zealand and CCHV population may be a factor in relation to the consumer experience of culturally safe communication skills. Although the small survey sample may bias the results, it does increase the significance of teaching and enabling implementation of culturally safe practice and communication when considering known health inequities. This may be an area for further exploration and highlights the importance of Indigenous input into this project.

This project has confirmed the need for accessible, effective communication observation and feedback from a person and whānau perspective. AI may have a role in this given the workforce education challenges we have highlighted. Despite the small numbers of survey respondents, the input from consumer and clinician respondents, as well as the clinical project team members’ own experiences, support the overarching findings that the traditional approach to teaching these skills is lacking. This includes attending in person training in our currently resource constrained environment and receiving feedback in the workplace (the apprenticeship model).

If our clinicians are not regularly experiencing learning opportunities in the classroom or in clinical settings and are not receiving feedback in a safe and supportive way, they are not likely to build and use the skills people and whānau say they need. Equally, learning that has occurred has not always translated to skills that effectively support PWCC as suggested by the literature and our consumer group. The potential disconnect between the person and whānau experience and the clinician’s perceptions of interactions is a gap, and therefore a learning need we have identified. Addressing these issues requires improved access to communication training that varies with the learners’ experience, confidence and skill, alongside regular and trusted feedback mechanisms, and the creation of safe learning environments that prioritise cultural safety and individual needs. The feedback the learners receive needs to be from the person and whānau perspective to bridge this gap.

An AI feedback tool may be a feasible option that can bridge some of the gap identified. Ninety percent of respondents stated they would be open to using an interactive AI tool that could provide evidence-based feedback and suggestions for improving their communication skills to support PWCC and shared decision making. The staff survey and the clinician focus group indicated that the potential for individualised and valid feedback, which is contextualised to the New Zealand context, incorporates cultural safety, and that can be accessed easily at any time, was seen as a potential advantage of this option over the current state.

However, concerns were also raised in relation to validity, data security, potential lack of Indigenous perspectives, perpetuation of stereotypes, environmental impacts, and whether the tool would offer an engaging way of learning. To mitigate this, any tool would need to be co-designed and tested with consumers to ensure that the feedback and coaching given was representative of their perspectives. If designed and built in this way, with appropriate governance, AI may provide a valid, personalised, and more easily accessed learning opportunity. AI has the potential to provide a foundational learning experience to complement more resource intensive simulation-based education.

Limitations

The low response rate to the clinician survey may not adequately reflect the entire workforce views. Clinicians who attended the focus group may have been more invested in communication education or be biased for or against AI. They may have stronger opinions than other members of the workforce, although their inputs echoed the survey findings. The consumer group was not representative of the general population.

Implications

The implications of this work signal the need for effective communication education in healthcare, specifically focussing on PWCC. This must include methodologies that support embedding of learning into practice. Tools will need to be developed to provide accessible and supportive feedback to clinicians. These should be co-designed to ensure they truly reflect consumers perspectives.

Conclusion

There may be merit in investigating the ability to build an AI feedback tool for more rigorous research and testing of validity, and the impact on learning and skill development. The understanding and transparency of any environmental impacts of such a tool, as well as the importance of Indigenous and broad consumer input into a tool’s vector build, design and outputs has been highlighted. Appropriate governance is important. Alongside these key features, the co-design approach needs to remain at the forefront to ensure the PWCC aim is achieved. The project team are investigating options to further this work.

View Appendix.