Around 9out of 100 individuals have limited English proficiency.

  It is believed that there are approximately6000 languages spoken in the world.  Whenwandering around in modern Britain, the South East to be precise, it sometimesappears that you can hear most of these languages. More so when you walk intoany large NHS Trust in the city we reside in. There are many challenges that the multicultural and multilingual worldbrings. 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.

Manypeople from different cultures and backgrounds walk through the doors ofgeneral practices in London every day.  Iam currently training in a busy north London practice, and whilst on placementI have observed many encounters were language is a great barrier.  The English language barrier versus othernative languages has made it difficult for healthcare professionals to do theirjob to their full potential, unnecessary consequences can cause huge mistakes inthe practice of medicine due to common misconceptions of the language beingspoken.   But how can we optimize the care andinformation they receive?Mostoften within general practice patients and healthcare professionals do notspeak the same language. Effective communication with patients in primary careis an essential part of the planning and delivery of appropriate high-qualityand safe patient care. Language and cultural differences are the maincommunication barriers in which I observed. Within thehealthcare sector, miscommunication can be life-threatening. There is a greatrise in the number of migrant patients and members of staff who areforeign-trained, this means that when one or both the healthcare practitionerand patient are speaking a second language there are increasingly likely to be communicationerrors.

Systematically there is limited research that addresses this issue. The aimof this essay is to understand language barriers and miscommunication that mayoccur in healthcare settings between patients and healthcare practitioners,especially where at least one of the speakers is using a second (weaker)language.Itis important that healthcare professionals understand that the key to goodholistic care is communication, this is because patients require informationand reassurance regarding their care.  Communicationis something we do every day, it is the process of receiving and sendingmessages between two or more people.  It isnot just talking to each other that defines communication, but it is how werespond to each other in many different ways (Langs,1983).  There are many different examples ofcommunication, 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.

This can be done duringan assessment when a patient arrives at the practice.  Netheheless, it has been argued thatcommunication barriers can prevent effective and appropriate care beingprovided to patients.  As Stuart andSundeen (1995), states that communication can either create barriers or aid inthe development of a therapeutic relationship. By simply observing an individual, many problems can be discovered.  If the patient has any visual impairments,physical disability or illness, observation can be used to determine whichlanguage is being used.  Bearing in mindthat any of the issues stated could control the way the individual is able tocommunicate.

Withinour general practices individuals of all nationalities deserve the best carepossible.  However, misunderstanding of differentlanguage barriers puts a restraint on patient care which can sometimes lead to unnecessaryand life-threating mistakes.  One of themost important tools that we use to provide outstanding patient care as well asimprove patient satisfaction is communication. Lower patient satisfaction scores, illnesses or worse things can oftenoccur when streaks of communication is crossed.In thehealthcare sector miscommunication can be life-threatening. There is a rise innumber of foreign-trained members of staff and patients, which means thaterrors in communication between patients and healthcare staff when a secondlanguage is spoken between one or both are increasingly likely.

Hiring aninterpreter who can speak the patient’s language as well as aid the healthcareprofessional in making the appropriate choices towards making the individualbetter, can help prevent fatal mistakes from occurring.  As simple as this solution may sound, manygeneral practices have no access to an interpreter and healthcare professionalshave little training in dealing with people of a different language.  An additional problem which arises withinterpreters is that, patients tend to have a concern with indirect communicationwith the health professional.

  Even withan interpreter, there is still a large chance that there could be misinformationbetween the healthcare professional and patient, missing key information thatcould endanger the life of the patient.For day to day and informal conversations or discussions, theuse of a non-professional interpreter, such as friends, bilingual member of staffor even a family member poses to raise a few ethical issues, however the use ofinterpreters who are untrained for issues relating to health or carediscussions is usually followed by legal and professional challenges fornurses, as well as patient disclosure implications. According to the NMC (2008)patients’ rights to confidentiality must be respected by the nurse.  Health Scotland (2008) states that it is never recommended forchildren to be used as interpreters, as they may become distressed, may lack theunderstanding and maturity of what is being communicated and also the patientbe may be reluctant to disclose certain information through a child.  Moreover nurses cannot be entirely sure if theinformation that is being translated to the patient is correct (Black, 2008),but nurses are required to to disclose health and treatment information, if ithas been requested by the patient (NMC, 2008).

 There isan increase in communication errors for already anxious patients which resultsto the rise in psychological stress as well as medical discrepancies; this issomething that language-congruent individuals encounter.  When patients and healthcare practitionerscommunicate in different languages, understanding the actual language withinthe context of a medical encounter is therefore critical for understanding thelanguage.  Due to this, patients are morelikely to fail in complying with instructions or elect from having potentiallylifesaving treatment.  That is why it iscrucial to accurately convey the likelihood of associated risk factors as wellas communicating the details of a treatment or diagnosis.When thefirst language of a patient is conflicting with that of the wider community andthe practitioner, it is not yet clear how health related risks is accuratelyand appropriately conveyed.  The use ofinadequately mastered language by clinicians is more likely to lead tomiscommunications according to evidence.

 Certain feelings, such as distress and pain are described differently byindividuals from different cultural groups, which complicate matters even further.  Even when competence in the language is high,metaphors, culturally-specific terms or expressions can be challenging tonavigate.  Furthermore, when interpretersare unavailable and clinicians lack the cultural and linguistic skills needed,it requires the patients to rely on bilingual medically inexperienced relativesor non-medical staff, this compromises worsening health outcomes and thequality of care for migrant communities.Within alanguage-discrepant medical communication setting, there are at least threetheoretical approaches to understanding why communication problems arise.  The first approach is discussed by Segalowitzand Kehayia, which is called a psycholinguistic approach, this approach focuseson the way in which the speaker directs the attention of focus of the otherindividual to key elements of their message, and this is done by using syntacticand semantic features of the language to appropriately package the message.

Thesecond theoretical approach examines the conversational dynamics ofpatient-doctor interactions.  The powerrelation differences between patient and doctor, also how the use of languageboth serves as a tool for manipulates them and reflects these relationships, iswhat this approach focuses on.  Not muchis known in regards to the social dynamics in which operates healthcarelanguage-discrepant.Theframework of Communication Accommodation Theory (CAT) is the third theoreticalapproach.  This approach has particularrelevance for the comparison of language-congruent and language-discrepantcommunication.  Firstly, The CommunicationAccommodation Theory puts forward that speakers attempt to converge theirmanner of speaking in order to achieve significant social goals aroundaccomplishing social identity, approval etc.

secondly the efficiency ofcommunication is reflected by the extent in which speakers converge, thirdlyconvergence is viewed as both normative and positive.  And finally in manner of speaking, divergenceis normally perceived negatively and reflects a specific intention. CommunicationAccommodation Theory (CAT) is also a convenient framework which is used to examinethe dynamics of patient-practitioner communication.   An inability in some cases to achieveconvergence (i.e. appearing similar in speech) can usually affect the qualityof the working relationship between the patient and the practitioner but alsohow the speakers perceive each other. The main goal is identifying the specific impacts that languagediscrepancy has as well as what the patient-practitioner communicationconsequences are.

It isstated that communication is not simply a facilitator or an adjunct of healthcare, communication is also a core component according to Schyve (2007).  It has long been recognized that goodcommunication between patients and providers is important. Medicines mostessential technology is language, which is the principle instrument forconducting its work (Jackson, 1998).  Clark (1983) observed that the work of a veterinarian and a physician (orother health providers) would almost be identical.Therehas 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, recoveryfrom symptoms, pain, physiological measure of blood pressure am blood glucaose)(Kaplan et al, 1989; Williams et al, 1998; Teutch, 2003; Stewart, 1995; Stewartet al, 1999; stewart et al, 2000) and also the quality of communication.  Improved health outcomes have been linked tothree basic communication processes.  Thefirst process which has been identified is improved health outcomes, the secondprocess is the control of dialogue by the patient, and finally the last processis the established rapport ( Kaplan et al, 1989).  All of these processes are put at risk in encountersof language discordant.

Patientswho do not speak the same language as their provider are put in the same risk categoryof poor communication as all other patients. Nethertheless, other additional risks are presented with languagebarrier.  As simple as it may seem toimprove the provider’s general communication skills it is not enough to addressthe risk that are encounted by patients who do not speak the samelanguage.

  An increased likelihood ofmalpractice complains and claims, risk to providers are all caused by poorcommunication (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.   Eventhough these are different concepts, equally, there have been issues ofcultural responsiveness or competence and linguistic, which have often beenconflated.

  Between health care providersand patients, there have been many different approaches addressing culturaldifferences.  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 suggesting culturalsafety (Coup, 1996) or cultural humility (Tervelon&Murray-Garcia, 1998) asalternatives.  In aculturally diverse society, the proposed preferred strategy for quality care ispatient centred care (Epner & Baile, 2012). It has been concluded that if the ethnic and racial disparities are tobe addressed, language barrier will be the target.  This is not because they are the mostdocumented 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 focusedon mainly experiences with care by patients and communities, it has beenidentified that within the minority communities themselves, language barriers isalso a priority (Stevens, 1993; Ngwakongnwi et al, 2012).Fewer visitsfor non-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 states that healthcare visits are significantly more likely to be fewer for individuals withlimited English proficiency.

  Studies conductedby Ayanian et al (2005) found that patients with language barriers are lesscontent with communication from doctors, staff helpfulness as well as givinglow assessment of psychosocial care.  Individualswho experience problems in regards to their care have been identified to be theones who experience language barriers with their providers according tostudies.When languagebarrier is present, a review of literature has revealed that there isconsistently a significant 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 incomplete history,misinformation for treatment plans, misdiagnosis and the patient usuallylacking understanding of his prescribed treatment and condition.Languagebarriers 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 physicalactivity there is less of a chance of the patient being counselled (Eamanond etal, 2009).  There are only a small numberof patients who lack fluency in the English language that have reported receivingcounselling on health and lifestyle or for a patient suffering fromhypotension, heart disease or diabetes, getting the advice to have their bloodpressure checked on a regular basis (Kenik et al, 2014).In thearea of reproductive 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 limited Englishproficient individuals.  A particularconcern in regards to the fear of loss of confidentiality leads to worrieswhich may be stigmatizing or embarrassing.Anotherparticular area in which language barrier has great impact on is pain management.

  Higher levels of pain control, greater helpfulnessfrom their provider to treat their pain and timely pain treatment were reportedby obstetrical patients who always received interpreters, in comparison to tothose who do not always receive interpreters, this has been identified by the studyby Jimenez et al (2014).  Further studieswhich have investigated ethnic/racial differences in terms of management ofpain, has also identified that language also contributes to the control ofpain.  An example of this is Cleeland etal (1997), who found that compared to 50% of non-minority patients, only 35% ofminority patients with cancer, received recommended guideline analgesicprescriptions.Theimpact of language barriers on management of chronic disease management hasbeen the main focus of many studies. But the area that has received the mostattention and a particular concern at this current time is the management ofasthma and diabetes.  Due to limitedfluency in the English language, risk factors have been noted in the managementof diabetes.  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 theageing population, 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 proficiency throughouttheir working lives, as a result of the ageing process tend to loose thissecond 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.Languagebarrier also affects 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).Criticalstandards in the delivery of ethical, quality care are ensuring informedconsent is obtained aswell as maintaining patient confidentiality.

  Informed comsent is not achieved for patientswith limited English proficiency accordinf to evidence.Anothercritical area that 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 more likelyfor English proficient individuals to report issues understanding the purposeand category of medication than limited English proficient individuals.  There is a lack in knowledge of the frequencyand dosage of the drug.

A long term solutionto this issue will be for our healthcare system to invest and provide a consistentdominant interpreter service, for providers as well as patients, that will beavailable at all times to facilitate, offering optimal communication betweenproviders and patients, as this will improve patient safety andsatisfaction.  However, in the meantime, aneffort must be put forth to help these individuals. Short term solutions suchas 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 incommunication which is encounted between healthcare professionals and patientscan cause ineffective treatment plans and misdiagnosis.  It is a requirement for nurses to meet communicationand language barriers and also to take the necessary actions to meet the needsof ethnic minority patients, this ensures that the information that has beendelivered is understood (NMC, 2008). This is of great importance as it allows understanding of the views ofpatients, expectation of the delivery of care as well as their thoughts, thiswill then enable the nurse to meet their needs.

Effective communication takes into accountof, cultural differences, language and also health literacy, which are all seenas the way to safe health care.  The mostfrequent root cause of serious events that occurs in the healthcare setting isdue to communication.  Many studies haveidentified that limited English proficiency patients suffer serious adverseoutcomes than English speaking patients. In order for health care professionals to achieve high quality and safecare, cultural, linguistic and health literacy barriers to patient needs to beaddressed immediately.There aremany impacts that effective communication can have on the quality of care inwhich nurses provide to patients.  In thecase where limited or no English is present, legal, professional and ethicalchallenges and 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 healthcare professionals are tomitigate communication issues and offering the best care possible to ourdiverse patient population.

  There needsto be an awareness of the many difficulties patients with limited English proficiencyhave to face.  We must create anenvironment that is welcoming, and encourage these individuals to seek the carethat they need, even if there is a language barrier.

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