The aim of this essay is tounderstand language barriers and miscommunication that may occur in ahealthcare setting between patients and healthcare practitioners, especiallywhere at least one of the speakers is using a second (weaker) language. It is important that healthcareprofessionals understand that the key to good holistic care is communication,particularly since patients require information and reassurance regarding theircare.  Communication is something we do every day, it is the process ofreceiving and sending messages between multiple people.  It is not justtalking to each other that defines communication, but it is how we respond toeach other in many different ways (Langs,1983).  There are many variedexamples of communication, such as, reading, singing, talking, writing and bodylanguage.  In order for communication to be effective, it first needs tobe established as well as maintained. In terms of a healthcare setting, thiscan be done during an assessment when a patient arrives at the practice.

Stuartand Sundeen (1995), state that communication can either create barriers andthis is the case as it is argued that communication barriers can preventeffective and appropriate care being provided to patients however they also debatethat it may aid in the development of a therapeutic relationship.In some instances, by simplyobserving an individual, many problems which can hinder communication are ableto be discovered.  If the patient has any visual impairments, physicaldisability or illness, observation can be used to determine which language isbeing used or the way the patient is able to communicate with the healthcareprofessional, as any of the issues stated could control the way the individualis 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 putsa restraint on patient care. Miscommunication in any instance could lead topotential issues however within the health care sector miscommunication mayresult in lower patient satisfaction scores, illnesses or could even belife-threatening when streaks of communication are crossed.

Hence, one of themost important tools that we use to provide outstanding patient care as well asimprove patient satisfaction is communication. Around 9 out of 100 individualshave limited English proficiency.  It is believed that there areapproximately 6000 languages spoken in the world.  When wandering aroundin modern Britain, the South East to be precise, most of these languages areapparent. More so when you walk into any large NHS Trust in the city we residein.

  There are many challenges that the multicultural and multilingualworld brings. The question is, if we struggle to make sense of each other’sworlds, how do we work together as well as support each other.Many people from different culturesand backgrounds walk through the doors of general practices in London everyday.  I am currently training in a busy North London practice, and whilston placement I observed many encounters where language barriers became anobstacle.  The English language barrier in comparison to other nativelanguages has made it difficult for healthcare professionals to perform theirjob to their fullest potential. This subsequently leads to unnecessary mistakesin the Practice of Medicine due to miscommunications because of the differencesin language.

 But how can we optimize the careand information they receive? Language and cultural differencesare the main communication barriers in which I have observed within GeneralPractices, where patients and healthcare professionals not speaking the samelanguage is something that has now become an occurrence. This is despiteeffective communication with patients in primary care being an essential partof the planning and delivery of appropriate high-quality and safe patient care.Overtime there has been an increasein not only the number of migrant patients however also in the staff who areforeign-trained. Consequently, the likelihood of communication errors rises asEnglish may be a second language in which some still aren’t proficient in andwhen either the healthcare practitioner or patient attempt to communicate witheach other on this basis, there is likely to be misinterpretations or confusionin what they are trying to put across. In addition, methodically there islimited research into this that addresses this issue.There is a rise in number offoreign-trained members of staff and patients, which means that errors incommunication between patients and healthcare staff when a second language isspoken between one or both are increasingly likely. Hiring an interpreter whocan speak the patient’s language as well as aid the healthcare professional inmaking the appropriate choices towards making the individual better, can helpprevent fatal mistakes from occurring.  As simple as this solution maysound, many general practices have no access to an interpreter and healthcareprofessionals have little training in dealing with people of a differentlanguage.

On the other hand, a problem which arises with the use ofinterpreters is that patients tend to have a concern with indirectcommunication with the health professional. Vital information that couldsignificantly affect the diagnosis may be omitted as the patient does not feelcomfortable disclosing this with the interpreter. Even with an interpreter,there is still a large chance that there could be misinformation between thehealthcare professional and patient, missing key information that couldendanger the life of the patient. The use of anon-professional interpreter, such as friends, bilingual member of staff oreven a family member can erupt a few ethical issues, the issue with usinguntrained interpreters for issues relating to health or care discussions canusually raise legal and professional challenges for nurses, as well as patientdisclosure implications The NMC (2008) states that patients are entitled to theirconfidentiality and this must be respected by the nurse.  Health Scotland (2008)advises that it is not recommended for children to be substituted asinterpreters, as they may become distressed, may lack the understanding andmaturity of what is being communicated and also the patient be may be reluctantto disclose certain information to a younger person. Nurses cannot be entirelysure if the information that is being translated to the patient is correct(Black, 2008). (NMC, 2008) requires nurses to disclose health and treatmentinformation if it has been requested. For patients sufferingfrom anxiety related illnesses there will be miscommunication from the initialstage.

In result of this psychological stress from the patient will becomeapparent as well as medical discrepancies possibly displayed from thehealthcare professional. In the scenario of a patient and a healthcareprofessional are communicating in different languages, it is important thatpatients fully take in the advice the practitioner in a medical context.Nevertheless, because there is a mismatch in languages, patients are morelikely to fail in adhering to the professional’s directions and in some casessaving their life. This is why it’s essential that there is a clear understandingbetween the doctor and patient.In the instance that thepatient’s fluent language is conflicting with wider community and thepractitioner, it will distort the health related risks from the patient to thepractioner and prevents resolutions to be accurately and appropriatelyconveyed. 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 tonavigate.  Furthermore, when interpretersare unavailable and clinicians lack the cultural and linguistic skills required.Patients have no choice but to rely on bilingual medically inexperiencedrelatives or non-medical staff. This heightens the chance of worsening healthoutcomes and the quality of care for the minority communities.Within alanguage-discrepant medical communication setting, there are at least threetheoretical approaches to understanding why communication problems arise. Within alanguage-discrepant medical communication setting, there are at least threetheoretical approaches to understanding why communication problems arise. The first approach called the Psycholinguistic Approach concentrates on the wayin which the speaker directs the attention of focus of the other individual tokey elements of their message. Segalowitz and Kehayia debates this is done byusing syntactic and semantic features of the language to properly package themessage.

 The second theoreticalapproach looks at the conversational dynamics of patient-doctorinteractions.  It explores the differences in terms of the balance ofpower between the patient and doctor, as well as how the use of language couldboth serve as an instrument that manipulates them and reflect the relationship. The framework ofCommunication Accommodation Theory (CAT) is the third theoreticalapproach.  This approach carries weight particularly when comparinglanguage-congruent and language-discrepant communication. The CommunicationAccommodation Theory  puts forth the idea that speakers attempt to adjusttheir way of speaking to reach particular social goals that centre aroundgaining some sort of social identity, approval etc.

Secondly, the CAT theorydescribes the efficiency of communication being indicated by the level in whichspeakers converge. Thirdly, convergence is seen as being both normative and positiveand lastly to some extent, divergence is typically received negatively andimplies a specific intent. Furthermore, CommunicationAccommodation Theory (CAT) can also be used as a basis in which to study thedynamics of patient-practitioner communication.

  If in certain instancesconvergence isnt able to be reached (i.e. speech likenesses) this can not onlyimpact the standard of the working relationship between the patient and theprofessional but additionally the way the speakers subsequently regard oneanother.  The key objective is recognising what exact affects thatlanguage discrepancy has in addition to what the patient-practitionercommunication repercussions may be.The fundamentality that isplaced on good communication between patients and providers is something thathas been widely acknowledged and that Schyve (2007) also states is not simply afacilitator or an adjunct of health care, but is also a core component.Furthermore, Jackson (1998) suggests that medicines most essential technology islanguage, which is the principle instrument for conducting its work, that onlyacts to further reinforce this idea.   There has been reviews inliterature in regards to patient-provider communication, which specifies thatthere is a link between the effects on the satisfaction of patients in additionto 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.

  Improvedhealth outcomes have been connected to three basic communicationprocesses.  The first process which has been identified is improved healthoutcomes, the second process is the control of dialogue by the patient, andfinally the last process is the established rapport ( Kaplan et al,1989).  All of these processes are placed into jeopardy in instances oflanguage discordant. Nethertheless, otheradditional risks are presented with language barrier.

  As simple as it may seem to improve theprovider’s general communication skills it is not enough to address the riskthat are encounted by patients who do not speak the same language.  An increased likelihood of malpracticecomplains and claims, risk to providers are all caused by poor communication(Domino et al, 2014; Lussier and Richard, 2005).  There are many literature focusing oncommunication between medical personnel, including patient handovers, but notmuch on the safety of patient literature relating to communication has focusedon miscommunication between patient and provider.   Even though these aredifferent concepts, equally, there have been issues of cultural responsivenessor 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, culturalcompetence, cultural proficiency, cultural appropriateness, congruence,cultural sensitivity and cultural awareness. All these approaches are based on different assumptions.

  Particularly cultural competence, which haspotential pitfalls and has been identified with several authors suggestingcultural safety (Coup, 1996) or cultural humility (Tervelon-Garcia,1998) as alternatives.  In a culturally diversesociety, the proposed preferred strategy for quality care is patient centredcare (Epner & Baile, 2012).  It hasbeen concluded that if the ethnic and racial disparities are to be addressed, languagebarrier will be the target.  This is notbecause they are the most documented source of disparities but because for atruly patient-centred care, communication is a basic requirement (Saha , 2007).  According to researchthat has been focused on mainly experiences with care by patients andcommunities, it has been identified that within the minority communitiesthemselves, language barriers is also a priority (Stevens, 1993; Ngwakongnwi etal, 2012).Fewer visits fornon-urgent medial problems and lower frequency of general check-ups areassociated with a language barrier (Derose et al., 2000; Pearson et al.2008).

  Fiscella et al (2002) also statesthat health care visits are significantly more likely to be fewer forindividuals with limited English proficiency. Studies conducted by Ayanian et al (2005) found that patients withlanguage barriers are less content with communication from doctors, staffhelpfulness as well as giving low assessment of psychosocial care.  Individuals who experience problems inregards to their care have been identified to be the ones who experiencelanguage barriers with their providers according to studies.When language barrier ispresent, a review of literature has revealed that there is consistently asignificant difference in compliance and understanding.  Lack of understanding of what has been saidis usually the reason why patients are not satisfied.  This results in lower adherence to theprescribed treatment.

  In the medicalencounter, poor communication usually results to inaccurate and incompletehistory, misinformation for treatment plans, misdiagnosis and the patientusually lacking understanding of his prescribed treatment and condition.Language barriers canlead to poorer controlling of disease outcomes and management, even if thediagnosis of a condition is correct.  Forexample, in the case of diet and physical activity there is less of a chance ofthe patient being counselled (Eamanond et al, 2009).  There are only a small number of patients wholack fluency in the English language that have reported receiving counsellingon health and lifestyle or for a patient suffering from hypotension, heartdisease or diabetes, getting the advice to have their blood pressure checked ona regular basis (Kenik et al, 2014).In the area ofreproductive health and sexuality, language barriers present additionalchallenges.  According to Coronado et al(2007), counselling and testing for sexually transmitted diseases (STI) andhuman immunodeficiency virus (HIV) may be less likely received by limitedEnglish proficient individuals.

  Aparticular concern in regards to the fear of loss of confidentiality leads toworries which may be stigmatizing or embarrassing.Another particular areain which language barrier has great impact on is pain management.  Higher levels of pain control, greaterhelpfulness from their provider to treat their pain and timely pain treatmentwere reported by obstetrical patients who always received interpreters, incomparison to to those who do not always receive interpreters, this has beenidentified by the study by Jimenez et al (2014).  Further studies which have investigatedethnic/racial differences in terms of management of pain, has also identifiedthat 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 minoritypatients with cancer, received recommended guideline analgesic prescriptions.

The impact of languagebarriers on management of chronic disease management has been the main focus ofmany studies. But the area that has received the most attention and aparticular concern at this current time is the management of asthma anddiabetes.  Due to limited fluency in theEnglish language, risk factors have been noted in the management ofdiabetes.  These include fewer footchecks, less likelihood of a self-monitoring blood glucose being performed,less likelihood of receiving education on diabetes and also less wellcontrolled symptoms of diabetes (Eamaranond et al, 2009).

Within the ageingpopulation, it has been identified that increasing challenges around languageaccess are being reported by health providers, states Koehn (2009).  Bouchard et al (2009) also states thatconcerns have been expressed by elderly minority language speakers aroundcommunication.  It has been observed thatmany clients who have had a significantly high level of English proficiencythroughout their working lives, as a result of the ageing process tend to loosethis second language ability, even when dementia is absent (Clyne, 2011).  When under stress, the first language of manyolder 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 noclear reasons for this attrition.Language barrier alsoaffects the quality of end of life care (Granek et al, 2013).  In comparison to patients with family membersreceiving information who are English proficient, those with non English familymembers are at a higher risk of fewer information regarding the illness oftheir loved ones (Thornton et al, 2009).

Critical standards inthe delivery of ethical, quality care are ensuring informed consent is obtainedaswell as maintaining patient confidentiality. Informed comsent is not achieved for patients with limited Englishproficiency accordinf to evidence.Another critical areathat language barrier affects is medication use.  It has been identified by many studies of thehigh rise in errors in medication amongst individuals who face languagebarriers.  Studies have shown thatincreased risk of complications along with less control of symptoms areapparent when language barrier is present (Dilworth et al, 2009).  Barton et al (2013) found that it is morelikely for English proficient individuals to report issues understanding thepurpose and category of medication than limited English proficient individuals.

  There is a lack in knowledge of the frequencyand dosage of the drug.A long term solution to this issue will be for ourhealthcare system to invest and provide a consistent dominant interpreterservice, for providers as well as patients, that will be available at all timesto facilitate, offering optimal communication between providers and patients,as this will improve patient safety and satisfaction.  However, in the meantime, an effort must beput forth to help these individuals. Short term solutions such as using visualmethods.

  For example, showing pictures,using simple and plain language, avoiding medical jargons, photographs orpictographs demonstrating techniques and medication use.  According to RCN (2006)and Divi et al (2007), difficulties in communication which is encounted betweenhealthcare professionals and patients can cause ineffective treatment plans andmisdiagnosis.  It is a requirement fornurses to meet communication and language barriers and also to take thenecessary actions to meet the needs of ethnic minority patients, this ensuresthat the information that has been delivered is understood (NMC, 2008).  This is of great importance as it allowsunderstanding of the views of patients, expectation of the delivery of care as wellas their thoughts, this will then enable the nurse to meet their needs.Effective communicationtakes 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 seriousevents that occurs in the healthcare setting is due to communication.

  Many studies have identified that limitedEnglish proficiency patients suffer serious adverse outcomes than Englishspeaking patients.  In order for healthcare professionals to achieve high quality and safe care, cultural, linguisticand health literacy barriers to patient needs to be addressed immediately.There are many impactsthat effective communication can have on the quality of care in which nursesprovide to patients.  In the case wherelimited or no English is present, legal, professional and ethical challengesand issues are raised, in meeting the communication needs of thesepatients.  But despite this, implementingand planning ways and strategies to overcome language barriers, nurses can havemany positive effects on patients in this particular group.

Our job as healthcareprofessionals are to mitigate communication issues and offering the best carepossible to our diverse patient population. There needs to be an awareness of the many difficulties patients withlimited English proficiency have to face. We must create an environment that is welcoming, and encourage theseindividuals to seek the care that they need, even if there is a languagebarrier.   

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