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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 two or more 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.

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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.  The first approach is discussed by Segalowitz
and Kehayia, which is called a psycholinguistic approach, this approach focuses
on the way in which the speaker directs the attention of focus of the other
individual to key elements of their message, and this is done by using syntactic
and semantic features of the language to appropriately package the message.

The
second theoretical approach examines the conversational dynamics of
patient-doctor interactions.  The power
relation differences between patient and doctor, also how the use of language
both serves as a tool for manipulates them and reflects these relationships, is
what this approach focuses on.  Not much
is known in regards to the social dynamics in which operates healthcare
language-discrepant.

The
framework of Communication Accommodation Theory (CAT) is the third theoretical
approach.  This approach has particular
relevance for the comparison of language-congruent and language-discrepant
communication.  Firstly, The Communication
Accommodation Theory puts forward that speakers attempt to converge their
manner of speaking in order to achieve significant social goals around
accomplishing social identity, approval etc. secondly the efficiency of
communication is reflected by the extent in which speakers converge, thirdly
convergence is viewed as both normative and positive.  And finally in manner of speaking, divergence
is normally perceived negatively and reflects a specific intention.

Communication
Accommodation Theory (CAT) is also a convenient framework which is used to examine
the dynamics of patient-practitioner communication.   An inability in some cases to achieve
convergence (i.e. appearing similar in speech) can usually affect the quality
of the working relationship between the patient and the practitioner but also
how the speakers perceive each other. 
The main goal is identifying the specific impacts that language
discrepancy has as well as what the patient-practitioner communication
consequences are.

It is
stated that communication is not simply a facilitator or an adjunct of health
care, communication is also a core component according to Schyve (2007).  It has long been recognized that good
communication between patients and providers is important. Medicines most
essential technology is language, which is the principle instrument for
conducting its work (Jackson, 1998).  
Clark (1983) observed that the work of a veterinarian and a physician (or
other health providers) would almost be identical.

There
has been reviews in literature in regards to patient-provider communication,
which indicates that as well as the effects on the satisfaction of patients,
there is a correlation between specific health outcomes (for example, recovery
from symptoms, pain, physiological measure of blood pressure am blood glucaose)
(Kaplan et al, 1989; Williams et al, 1998; Teutch, 2003; Stewart, 1995; Stewart
et al, 1999; stewart et al, 2000) and also the quality of communication.  Improved health outcomes have been linked 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 put at risk in encounters
of language discordant.

Patients
who do not speak the same language as their provider are put in the same risk category
of poor communication as all other patients. 
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&Murray-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 barrier.

 

 

 

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