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, it sometimes
appears that you can hear most of these languages. 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.

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 have observed many encounters were language is a great barrier.  The English language barrier versus other
native languages has made it difficult for healthcare professionals to do their
job to their full potential, unnecessary consequences can cause huge mistakes in
the practice of medicine due to common misconceptions of the language being

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

often within general practice patients and healthcare professionals do not
speak the same language. Effective communication with patients in primary care
is an essential part of the planning and delivery of appropriate high-quality
and safe patient care. Language and cultural differences are the main
communication barriers in which I observed.

Within the
healthcare sector, miscommunication can be life-threatening. There is a great
rise in the number of migrant patients and members of staff who are
foreign-trained, this means that when one or both the healthcare practitioner
and patient are speaking a second language there are increasingly likely to be communication
errors. Systematically there is limited research that addresses this issue.

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

is important that healthcare professionals understand that the key to good
holistic care is communication, this is because 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 different 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. This can be done during
an assessment when a patient arrives at the practice.  Netheheless, it has been argued that
communication barriers can prevent effective and appropriate care being
provided to patients.  As Stuart and
Sundeen (1995), states that communication can either create barriers or aid in
the 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 which
language is being used.  Bearing in mind
that any of the issues stated could control the way the individual is able to

our general practices individuals of all nationalities deserve the best care
possible.  However, misunderstanding of different
language barriers puts a restraint on patient care which can sometimes lead to unnecessary
and life-threating mistakes.  One of the
most important tools that we use to provide outstanding patient care as well as
improve patient satisfaction is communication. 
Lower patient satisfaction scores, illnesses or worse things can often
occur when streaks of communication is crossed.

In the
healthcare sector miscommunication can be life-threatening. 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.  An additional problem which arises with
interpreters is that, patients tend to have a concern with indirect communication
with the health professional.  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.

For day to day and informal conversations or discussions, the
use of a non-professional interpreter, such as friends, bilingual member of staff
or even a family member poses to raise a few ethical issues, however the use of
interpreters who are untrained for issues relating to health or care
discussions is usually followed by legal and professional challenges for
nurses, 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 for
children to be used 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 through a child.  Moreover nurses cannot be entirely sure if the
information that is being translated to the patient is correct (Black, 2008),
but nurses are required to to disclose health and treatment information, if it
has been requested by the patient (NMC, 2008). 

There is
an increase in communication errors for already anxious patients which results
to the rise in psychological stress as well as medical discrepancies; this is
something that language-congruent individuals encounter.  When patients and healthcare practitioners
communicate in different languages, understanding the actual language within
the context of a medical encounter is therefore critical for understanding the
language.  Due to this, patients are more
likely to fail in complying with instructions or elect from having potentially
lifesaving treatment.  That is why it is
crucial to accurately convey the likelihood of associated risk factors as well
as communicating the details of a treatment or diagnosis.

When the
first language of a patient is conflicting with that of the wider community and
the practitioner, it is not yet clear how health related risks is accurately
and appropriately conveyed.  The use of
inadequately mastered language by clinicians is more likely to lead to
miscommunications according to evidence. 
Certain feelings, such as distress and pain are described differently by
individuals 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 to
navigate.  Furthermore, when interpreters
are unavailable and clinicians lack the cultural and linguistic skills needed,
it requires the patients to rely on bilingual medically inexperienced relatives
or non-medical staff, this compromises worsening health outcomes and the
quality of care for migrant 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.

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

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.

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.

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.

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.  

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

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

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.

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.

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

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.

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).

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.

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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