The aim of this essay is to
understand language barriers and miscommunication that may occur in a
healthcare setting between patients and healthcare practitioners, especially
where at least one of the speakers is using a second (weaker) language.


It is important that healthcare
professionals understand that the key to good holistic care is communication,
particularly since patients require information and reassurance regarding their
care.  Communication is something we do every day, it is the process of
receiving and sending messages between multiple people.  It is not just
talking to each other that defines communication, but it is how we respond to
each other in many different ways (Langs,1983).  There are many varied
examples of communication, such as, reading, singing, talking, writing and body
language.  In order for communication to be effective, it first needs to
be established as well as maintained. In terms of a healthcare setting, this
can be done during an assessment when a patient arrives at the practice. Stuart
and Sundeen (1995), state that communication can either create barriers and
this is the case as it is argued that communication barriers can prevent
effective and appropriate care being provided to patients however they also debate
that it may aid in the development of a therapeutic relationship.

In some instances, by simply
observing an individual, many problems which can hinder communication are able
to be discovered.  If the patient has any visual impairments, physical
disability or illness, observation can be used to determine which language is
being used or the way the patient is able to communicate with the healthcare
professional, as any of the issues stated could control the way the individual
is able to communicate.

Within our general practices,
individuals of all nationalities deserve the best care possible.  However,
language barriers and the misunderstanding between individuals it proposes puts
a restraint on patient care. Miscommunication in any instance could lead to
potential issues however within the health care sector miscommunication may
result in lower patient satisfaction scores, illnesses or could even be
life-threatening when streaks of communication are crossed. Hence, one of the
most important tools that we use to provide outstanding patient care as well as
improve patient satisfaction is communication.


Around 9 out of 100 individuals
have limited English proficiency.  It is believed that there are
approximately 6000 languages spoken in the world.  When wandering around
in modern Britain, the South East to be precise, most of these languages are
apparent. More so when you walk into any large NHS Trust in the city we reside
in.  There are many challenges that the multicultural and multilingual
world brings. The question is, if we struggle to make sense of each other’s
worlds, how do we work together as well as support each other.

Many people from different cultures
and backgrounds walk through the doors of general practices in London every
day.  I am currently training in a busy North London practice, and whilst
on placement I observed many encounters where language barriers became an
obstacle.  The English language barrier in comparison to other native
languages has made it difficult for healthcare professionals to perform their
job to their fullest potential. This subsequently leads to unnecessary mistakes
in the Practice of Medicine due to miscommunications because of the differences
in language.


But how can we optimize the care
and information they receive?


Language and cultural differences
are the main communication barriers in which I have observed within General
Practices, where patients and healthcare professionals not speaking the same
language is something that has now become an occurrence. This is despite
effective communication with patients in primary care being an essential part
of the planning and delivery of appropriate high-quality and safe patient care.

Overtime there has been an increase
in not only the number of migrant patients however also in the staff who are
foreign-trained. Consequently, the likelihood of communication errors rises as
English may be a second language in which some still aren’t proficient in and
when either the healthcare practitioner or patient attempt to communicate with
each other on this basis, there is likely to be misinterpretations or confusion
in what they are trying to put across. In addition, methodically there is
limited research into this that addresses this issue.

There is a rise in number of
foreign-trained members of staff and patients, which means that errors in
communication between patients and healthcare staff when a second language is
spoken between one or both are increasingly likely. Hiring an interpreter who
can speak the patient’s language as well as aid the healthcare professional in
making the appropriate choices towards making the individual better, can help
prevent fatal mistakes from occurring.  As simple as this solution may
sound, many general practices have no access to an interpreter and healthcare
professionals have little training in dealing with people of a different
language. On the other hand, a problem which arises with the use of
interpreters is that patients tend to have a concern with indirect
communication with the health professional. Vital information that could
significantly affect the diagnosis may be omitted as the patient does not feel
comfortable disclosing this with the interpreter. Even with an interpreter,
there is still a large chance that there could be misinformation between the
healthcare professional and patient, missing key information that could
endanger the life of the patient.


The use of a
non-professional interpreter, such as friends, bilingual member of staff or
even a family member can erupt a few ethical issues, the issue with using
untrained interpreters for issues relating to health or care discussions can
usually raise legal and professional challenges for nurses, as well as patient
disclosure implications The NMC (2008) states that patients are entitled to their
confidentiality and this must be respected by the nurse. 

Health Scotland (2008)
advises that it is not recommended for children to be substituted as
interpreters, as they may become distressed, may lack the understanding and
maturity of what is being communicated and also the patient be may be reluctant
to disclose certain information to a younger person. Nurses cannot be entirely
sure if the information that is being translated to the patient is correct
(Black, 2008). (NMC, 2008) requires nurses to disclose health and treatment
information if it has been requested.


For patients suffering
from anxiety related illnesses there will be miscommunication from the initial
stage. In result of this psychological stress from the patient will become
apparent as well as medical discrepancies possibly displayed from the
healthcare professional. In the scenario of a patient and a healthcare
professional are communicating in different languages, it is important that
patients fully take in the advice the practitioner in a medical context.
Nevertheless, because there is a mismatch in languages, patients are more
likely to fail in adhering to the professional’s directions and in some cases
saving their life. This is why it’s essential that there is a clear understanding
between the doctor and patient.

In the instance that the
patient’s fluent language is conflicting with wider community and the
practitioner, it will distort the health related risks from the patient to the
practioner and prevents resolutions to be accurately and appropriately
conveyed. In a sector where a vast number of cultural groups is involved,
specific feelings including distress and pain can be portrayed differently,
which complicate matters even further. 
Even though in some cases, glimpses of the English language is shown;
Metaphors, culturally-specific terms or expressions can be challenging to
navigate.  Furthermore, when interpreters
are unavailable and clinicians lack the cultural and linguistic skills required.
Patients have no choice but to rely on bilingual medically inexperienced
relatives or non-medical staff. This heightens the chance of worsening health
outcomes and the quality of care for the minority communities.

Within a
language-discrepant medical communication setting, there are at least three
theoretical approaches to understanding why communication problems arise. Within a
language-discrepant medical communication setting, there are at least three
theoretical approaches to understanding why communication problems arise. 
The first approach called the Psycholinguistic Approach concentrates on the way
in which the speaker directs the attention of focus of the other individual to
key elements of their message. Segalowitz and Kehayia debates this is done by
using syntactic and semantic features of the language to properly package the

The second theoretical
approach looks at the conversational dynamics of patient-doctor
interactions.  It explores the differences in terms of the balance of
power between the patient and doctor, as well as how the use of language could
both serve as an instrument that manipulates them and reflect the relationship.

The framework of
Communication Accommodation Theory (CAT) is the third theoretical
approach.  This approach carries weight particularly when comparing
language-congruent and language-discrepant communication. The Communication
Accommodation Theory  puts forth the idea that speakers attempt to adjust
their way of speaking to reach particular social goals that centre around
gaining some sort of social identity, approval etc. Secondly, the CAT theory
describes the efficiency of communication being indicated by the level in which
speakers converge. Thirdly, convergence is seen as being both normative and positive
and lastly to some extent, divergence is typically received negatively and
implies a specific intent. 

Furthermore, Communication
Accommodation Theory (CAT) can also be used as a basis in which to study the
dynamics of patient-practitioner communication.   If in certain instances
convergence isnt able to be reached (i.e. speech likenesses) this can not only
impact the standard of the working relationship between the patient and the
professional but additionally the way the speakers subsequently regard one
another.  The key objective is recognising what exact affects that
language discrepancy has in addition to what the patient-practitioner
communication repercussions may be.

The fundamentality that is
placed on good communication between patients and providers is something that
has been widely acknowledged and that Schyve (2007) also states is not simply a
facilitator or an adjunct of health care, but is also a core component.
Furthermore, Jackson (1998) suggests that medicines most essential technology is
language, which is the principle instrument for conducting its work, that only
acts to further reinforce this idea.   

There has been reviews in
literature in regards to patient-provider communication, which specifies that
there is a link between the effects on the satisfaction of patients in addition
to the specific health outcomes for example how they recover from symptoms,
pain, physiological measure of blood pressure and blood glucose (Kaplan et al,
1989; Williams et al, 1998; Teutch, 2003; Stewart, 1995; Stewart et al, 1999;
stewart et al, 2000) as well as the quality of communication.  Improved
health outcomes have been connected to three basic communication
processes.  The first process which has been identified is improved health
outcomes, the second process is the control of dialogue by the patient, and
finally the last process is the established rapport ( Kaplan et al,
1989).  All of these processes are placed into jeopardy in instances of
language discordant.


Nethertheless, other
additional risks are presented with language barrier.  As simple as it may seem to improve the
provider’s general communication skills it is not enough to address the risk
that are encounted by patients who do not speak the same language.  An increased likelihood of malpractice
complains and claims, risk to providers are all caused by poor communication
(Domino et al, 2014; Lussier and Richard, 2005).  There are many literature focusing on
communication between medical personnel, including patient handovers, but not
much on the safety of patient literature relating to communication has focused
on miscommunication between patient and provider.  

Even though these are
different concepts, equally, there have been issues of cultural responsiveness
or competence and linguistic, which have often been conflated.  Between health care providers and patients,
there have been many different approaches addressing cultural differences.  These approaches include, cultural
competence, cultural proficiency, cultural appropriateness, congruence,
cultural sensitivity and cultural awareness. 
All these approaches are based on different assumptions.  Particularly cultural competence, which has
potential pitfalls and has been identified with several authors suggesting
cultural safety (Coup, 1996) or cultural humility (Tervelon-Garcia,
1998) as alternatives. 

In a culturally diverse
society, the proposed preferred strategy for quality care is patient centred
care (Epner & Baile, 2012).  It has
been concluded that if the ethnic and racial disparities are to be addressed, language
barrier will be the target.  This is not
because they are the most documented source of disparities but because for a
truly patient-centred care, communication is a basic requirement (Saha &
Fernabdez, 2007).  According to research
that has been focused on mainly experiences with care by patients and
communities, it has been identified that within the minority communities
themselves, language barriers is also a priority (Stevens, 1993; Ngwakongnwi et
al, 2012).

Fewer visits for
non-urgent medial problems and lower frequency of general check-ups are
associated with a language barrier (Derose et al., 2000; Pearson et al.
2008).  Fiscella et al (2002) also states
that health care visits are significantly more likely to be fewer for
individuals with limited English proficiency. 
Studies conducted by Ayanian et al (2005) found that patients with
language barriers are less content with communication from doctors, staff
helpfulness as well as giving low assessment of psychosocial care.  Individuals who experience problems in
regards to their care have been identified to be the ones who experience
language barriers with their providers according to studies.

When language barrier is
present, a review of literature has revealed that there is consistently a
significant difference in compliance and understanding.  Lack of understanding of what has been said
is usually the reason why patients are not satisfied.  This results in lower adherence to the
prescribed treatment.  In the medical
encounter, poor communication usually results to inaccurate and incomplete
history, misinformation for treatment plans, misdiagnosis and the patient
usually lacking understanding of his prescribed treatment and condition.

Language barriers can
lead to poorer controlling of disease outcomes and management, even if the
diagnosis of a condition is correct.  For
example, in the case of diet and physical activity there is less of a chance of
the patient being counselled (Eamanond et al, 2009).  There are only a small number of patients who
lack fluency in the English language that have reported receiving counselling
on health and lifestyle or for a patient suffering from hypotension, heart
disease or diabetes, getting the advice to have their blood pressure checked on
a regular basis (Kenik et al, 2014).

In the area of
reproductive health and sexuality, language barriers present additional
challenges.  According to Coronado et al
(2007), counselling and testing for sexually transmitted diseases (STI) and
human immunodeficiency virus (HIV) may be less likely received by limited
English proficient individuals.  A
particular concern in regards to the fear of loss of confidentiality leads to
worries which may be stigmatizing or embarrassing.

Another particular area
in which language barrier has great impact on is pain management.  Higher levels of pain control, greater
helpfulness from their provider to treat their pain and timely pain treatment
were reported by obstetrical patients who always received interpreters, in
comparison to to those who do not always receive interpreters, this has been
identified by the study by Jimenez et al (2014).  Further studies which have investigated
ethnic/racial differences in terms of management of pain, has also identified
that language also contributes to the control of pain.  An example of this is Cleeland et al (1997),
who found that compared to 50% of non-minority patients, only 35% of minority
patients with cancer, received recommended guideline analgesic prescriptions.

The impact of language
barriers on management of chronic disease management has been the main focus of
many studies. But the area that has received the most attention and a
particular concern at this current time is the management of asthma and
diabetes.  Due to limited fluency in the
English language, risk factors have been noted in the management of
diabetes.  These include fewer foot
checks, less likelihood of a self-monitoring blood glucose being performed,
less likelihood of receiving education on diabetes and also less well
controlled symptoms of diabetes (Eamaranond et al, 2009).

Within the ageing
population, it has been identified that increasing challenges around language
access are being reported by health providers, states Koehn (2009).  Bouchard et al (2009) also states that
concerns have been expressed by elderly minority language speakers around
communication.  It has been observed that
many clients who have had a significantly high level of English proficiency
throughout their working lives, as a result of the ageing process tend to loose
this second language ability, even when dementia is absent (Clyne, 2011).  When under stress, the first language of many
older patients is more likely to return. 
In the case where a patient is suffering from a cognitive impairment,
this attrition of second language may be more acute (Kieizer, 2011).  According to Murtagh (2011), there are no
clear reasons for this attrition.

Language barrier also
affects the quality of end of life care (Granek et al, 2013).  In comparison to patients with family members
receiving information who are English proficient, those with non English family
members are at a higher risk of fewer information regarding the illness of
their loved ones (Thornton et al, 2009).

Critical standards in
the delivery of ethical, quality care are ensuring informed consent is obtained
aswell as maintaining patient confidentiality. 
Informed comsent is not achieved for patients with limited English
proficiency accordinf to evidence.

Another critical area
that language barrier affects is medication use.  It has been identified by many studies of the
high rise in errors in medication amongst individuals who face language
barriers.  Studies have shown that
increased risk of complications along with less control of symptoms are
apparent when language barrier is present (Dilworth et al, 2009).  Barton et al (2013) found that it is more
likely for English proficient individuals to report issues understanding the
purpose and category of medication than limited English proficient individuals.  There is a lack in knowledge of the frequency
and dosage of the drug.

A long term solution to this issue will be for our
healthcare system to invest and provide a consistent dominant interpreter
service, for providers as well as patients, that will be available at all times
to facilitate, offering optimal communication between providers and patients,
as this will improve patient safety and satisfaction.  However, in the meantime, an effort must be
put forth to help these individuals. Short term solutions such as using visual
methods.  For example, showing pictures,
using simple and plain language, avoiding medical jargons, photographs or
pictographs demonstrating techniques and medication use.


According to RCN (2006)
and Divi et al (2007), difficulties in communication which is encounted between
healthcare professionals and patients can cause ineffective treatment plans and
misdiagnosis.  It is a requirement for
nurses to meet communication and language barriers and also to take the
necessary actions to meet the needs of ethnic minority patients, this ensures
that the information that has been delivered is understood (NMC, 2008).  This is of great importance as it allows
understanding of the views of patients, expectation of the delivery of care as well
as their thoughts, this will then enable the nurse to meet their needs.

Effective communication
takes into account of, cultural differences, language and also health literacy,
which are all seen as the way to safe health care.  The most frequent root cause of serious
events that occurs in the healthcare setting is due to communication.  Many studies have identified that limited
English proficiency patients suffer serious adverse outcomes than English
speaking patients.  In order for health
care professionals to achieve high quality and safe care, cultural, linguistic
and health literacy barriers to patient needs to be addressed immediately.

There are many impacts
that effective communication can have on the quality of care in which nurses
provide to patients.  In the case where
limited or no English is present, legal, professional and ethical challenges
and issues are raised, in meeting the communication needs of these
patients.  But despite this, implementing
and planning ways and strategies to overcome language barriers, nurses can have
many positive effects on patients in this particular group.

Our job as healthcare
professionals are to mitigate communication issues and offering the best care
possible to our diverse patient population. 
There needs to be an awareness of the many difficulties patients with
limited English proficiency have to face. 
We must create an environment that is welcoming, and encourage these
individuals to seek the care that they need, even if there is a language





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