Language Barrier in Healthcare

The qualitative study of Landmark and her team was participated by Norwegian physicians and patients as they explored series of recordings of physician’s prescribed therapy to their respective patients. Through these records, the presence of a patient-centered care and a shared decision making approaches were analyzed using 380 video-recorded patient-doctor interactions. Of these, 18 records became the primary source of information.

The study was conducted in a Norwegian teaching hospital from 2007 to 2008. Video records and transcripts were analyzed using conversation analysis or interactional machinery (where thematic analysis includes). Findings revealed that understanding was “seemed” to be ensured both by patient-centered care and shared decision making as portrayed in their actual or routine practices in the clinical area. On the other hand, potential disagreement or misunderstanding occurs when physicians and patients use their non-native language or when neutral responses by the patients were interpreted by the physicians as either agreeing or disagreeing.

The major implication of the findings of this study highlighted language barrier as potential cause of non-understanding/non-agreement. Moreover, the researchers emphasized that the observed good patient-centered approach in the actual clinical scenario may not be adequately sufficed especially when physicians encountered misunderstanding/disagreement and non-participation of patients in decision making process. Supportive to this include the origin of the native language of both participants and misinterpretation of patient’s neutral responses (e.g. agreeing/disagreeing, instead of misunderstanding/non-understanding). Although difficult and challenging, it is recommended that a model of “actual best practice” be developed with regard to the concept of patient understanding. Such actual best practice must not only be in terms of conversation but also reflect in patient’s actions or adherence to prescribed treatment. Lastly, formulating trainings (regarding communication strategies) which aim to address patient’s non-responsiveness, non-understanding, disagreement, or non-participation in decision making is essential in resolving language barriers, understanding patient’s needs and achieving a patient-centered decision-making.

Schwei and her fellow researchers claimed that language barriers in healthcare is a worldwide concern, particularly in Europe, Australia and Canada (other than the United States). These states have one thing in common – immigrants who experience language barriers in healthcare settings. In 2003, the Bush administration has implemented a change in US’ services for LEP (limited English proficiency) individuals. From this perspective, they aimed to describe the state of the language barrier literature in and out of the US (from 2003 to 2010) and compare studies which were conducted before and after such policy change. In addition, literature and studies outside US were reviewed to assess the global trends. Literature review and cross-sectional analysis were employed in their methodology. They had two-phase review. Phase 1 only included annotated bibliographies of 2003 (starting 1974, prior to Bush’ implementation of changes) and phase 2 involved analysis from 2003 to 2011 (after Bush’ implementation of changes).

Furthermore, criteria and parameters set in search and classification were similar in both phases. In their result, they found that the areas highlighted in their review included

• (a) access barrier
• (b) comparison study
• (c) interpreting practices
• (d) outcomes
• (e) patient satisfaction.

As they expected, studies focusing on language barriers have increased (since 2003) and this could be attributed to the policy change by the Bush administration. Also, in terms of perspectives in dealing with clients who have language barriers, the researchers revealed that it is more physician-focused within the US but nurse-focused outside the US. As a recommendation, problems pertaining to language barriers in healthcare delivery system around the world must be well-documented in order to accurately identify the problem and provide evidence-based solutions van Rose and her colleagues investigated the risks involved in patient safety caused by language barriers during their hospitalization period.

Moreover, they explored how language barriers were detected, reported, and bridged in a Dutch hospital care setting. In their methodology, they combined quantitative and qualitative research approaches in a sample of 576 ethnic minority in-patients. The study was participated by four urban hospitals in Netherlands. Nursing and medical records of concerned patients were reviewed and analyzed. Supplemental, yet, in-depth interviews with healthcare providers and in-patients were also conducted. The outputs, were compared to patients’ self-reported Dutch language proficiency tool. Aside from this, experts in language interpreters also aided in data analysis and interpretation. As a result, the researchers found that certain hospital care situations where there is language barrier include nursing-related activities such as administering drugs, pain and fluid balance management. Physician-related language barrier also exists in patient-doctor conversations regarding diagnosis, risk communications and acute situations.

More often, the relatives and significant others of these patients served as interpreters. In such cases, professional interpreters were not much used which could mean that professional interpreters were not as effective (as expected) to help in resolving language-barrier-related patient safety issues. These situations showed that risks were possible in hospitals with patients who experience language barriers. This gap could be serious when timeliness and promptness of delivering healthcare services of addressing patient’s needs is not addressed. As a general comment on this study, regardless of the nurse’s competent level of knowledge and skills, promptness in identifying language barrier is primordial to collecting accurate data and delivering safe nursing and medical management. Documentations of these must be secured for future study references concerning policy reviews and updates and in-service trainings regarding communication, language barrier and safety-related health issues.

The annotated bibliographies concerning language barrier, in relation to NSQHS’ communicating for safety standard, have significance to Australian nursing practice despite conducting such in healthcare settings of three different countries (Norway, United States and Netherlands, respectively). Nowadays, standards on healthcare delivery system are becoming uniformed at a considerable pace. Communication plays a substantial role in unifying these standards and ensuring safe delivery of healthcare services. Language barrier is an obvious obstacle to attaining this goal.

Landmark, et. al. (2017) merely focused on physician-initiated interactions with patients in assessing and planning treatment regimen. Physicians could not generate genuine patient participation because they did not stay with them more often. Furthermore, there were physicians who assumed that the patient understood the prescribed treatment regimen simply because he/she nodded or said “uhmm” or “yes.” These responses sometimes did not translate into actions or actual patient compliance. After conversing with patients, physicians would normally leave and just wait for reports or developing responses. On the other hand, nurses are great instruments in bridging this gap because they stay with the patient throughout his/her course of confinement. Considering the trust and rapport they established with their patients, nurses are the ones who can more effectively assess and empathize with them. At the same time, nurses are able to evaluate the actual progress and treatment compliance of the patients to prescribed treatment even before the physician does. As future Australian nurses who are cognizant to patient’s safety, we play crucial role in clarifying patient’s misunderstandings and relay these to the physicians even if they have already left the unit. This intervention further validates patient’s response, ensure full understanding of instructions and allows initiating modification of plan (if any).

In another study, Schwei, et. al. (2016) exposed a considerable increase in language barrier-themed studies after 2003 when Bush’s administration implemented access to healthcare services among people who are limited English proficient (LEP). Among people who greatly benefited included migrants. Currently, migrants prefer highly developed English-speaking countries. Among the advantages of choosing these are quality of life and access to quality healthcare delivery system. However, problem arises when they are not competent enough to speak and express themselves using English language, most especially when they are sick.

Central to addressing this concern are the nurses’ ability to grasp and understand patients’ health concerns regardless of the language they use. In Australia, where key cities are also cultural melting pots, dealing with patients who experience language barrier could occur. Since poor interpretation of patient’s chief complaints could lead to unsafe delivery of health interventions, nurses must be competent enough in analyzing such complaints by not merely grounding his/her judgment on patient’s lingual claims. As future Australian nurse, other interventions such as clinical eye (during inspection), use of context clues and other assessment tools/tests are helpful in clarifying confusions and refining patients claims until one arrives at properly identified patient’s needs.

In the last cited research, van Rosse, et. al. (2016) enumerated nursing interventions that may be unsafely delivered if language barriers were not promptly identified and resolved. They also mentioned the role of relatives as interpreter when language barrier is identified.

In Australian healthcare setting, the clientele are not the only culturally diverse members of the population. Nurses and allied health professionals also come from different cultural backgrounds. Although competent English is a requirement for employment, miscommunications may still occur between and among conversing parties if diction, accent, slang, pronunciation, enunciation or even dealing with newly hired immigrant employee are considered.

Moreover, the use of ISBAR has established itself as an indispensable tool in significantly lowering or solving misunderstanding between communicating members of the healthcare team. Finally, the role of family and significant others in patient care must not be ignored. They could serve as effective and efficient interpreters of patient’s concerns.

Works Cited

1. Landmark, B. T., Sandvik, H., Reinertsen, K. V., & Baerheim, A. (2017). How to ensure patient understanding in a consultation. Patient Education and Counseling, 100(5), 926-931.
2. Schwei, R. J., Del Pozo, S., Agger-Gupta, N., Alvarado-Little, W., Bagchi, A., Chen, A. H., ... & Solow, C. M. (2016). Language concordance as a determinant of patient satisfaction and compliance. Journal of General Internal Medicine, 31(5), 567-574.
3. van Rosse, F., de Bruijne, M., Suurmond, J., Essink-Bot, M. L., & Wagner, C. (2016). Language barriers and patient safety risks in hospital care: A mixed methods study. International Journal of Nursing Studies, 54, 45-53.
4. Bush, R. W. (2003). Executive Order 13166: Improving access to services for persons with limited English proficiency. Federal Register, 68(144), 47311-47314.
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