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Lost in translation

By Parveen Azam Ali | 09/13/2017

Language concordance between nurse and patient enhances care.

Photo of woman talking on cellphone
Nurses should communicate with patients in their native languages, when possible, to optimize care and minimize risk.

As a researcher, I am interested in exploring health inequalities. The two main issues I focus on are gender-based violence and health experiences related to ethnicity.

Parveen Azam AliWhen talking about ethnic differences and their impact on healthcare delivery and experiences, the role of communication cannot be overlooked. Communication between a patient and a nurse—or any other healthcare professional—requires use of a mutual language, which is known as language concordance. Trying to communicate with someone who does not speak the same language can be extremely challenging and may put patient safety at risk.

I became interested in researching the impact of language concordance between nurse and patient while working as a telephone triage nurse. From my research findings, I learned that prejudice and unconscious bias contribute to healthcare delivery that may not be as safe and effective as one might think.

English, Hindko, Punjabi, or Urdu?
I received my nursing education in Pakistan and am confident in my clinical judgment, clinical assessment skills, and ability to provide effective care. English is my fourth language. Hindko, Punjabi, and Urdu are my first, second, and third languages, respectively. I have never had issues in assessing or caring for patients who communicate either partially or totally in one of these languages.

While working as a registered nurse in the United Kingdom, I realized that my English colleagues did not like it when other colleagues and I who shared the same national and linguistic backgrounds spoke with each other in our native languages—in other words, in any language other than English. In being excluded from our conversation, they perhaps felt alienated. I conjectured that colleagues whose primary language was English were afraid that our conversations might have been about them or even against them. Some voiced their disapproval, while others conveyed their displeasure nonverbally. As a result, I tried to avoid speaking languages other than English at work, as did many of my colleagues who shared similar linguistic backgrounds.

I made my decision to avoid speaking in languages other than English when in the presence of native English speakers to prevent misunderstanding and foster positive relationships with colleagues. It wasn’t until I started working as a telephone triage nurse, however, that lack of language concordance posed the threat of negatively affecting patient care. Because of hospital rules, I was required to use a telephone interpreter when assessing patients with limited English proficiency who spoke only Punjabi or Urdu—languages I speak fluently.

Other multilingual nurses in our organization shared my experience. They, too, were not allowed to communicate directly with patients of the same linguistic background in their primary language but had to use telephone interpretation services. The rationale behind these practices—as explained by service managers—was to ensure quality and accuracy of information, as English-speaking nurses could not review such calls. I didn’t buy into this notion but tried to comply with the process by using interpreters. I found it very difficult.

Not what I heard!
When communicating through interpreters, I frequently noticed that the interpreter’s translation of the question I asked or the response by the patient was inaccurate. Since I could understand both the interpreter’s language and the patient’s language, I noticed these discrepancies. For example, I once was speaking to a mother who spoke Urdu about her child’s breathing problem, and the interpreter could not translate the question in a meaningful way to obtain the appropriate answer. If I hadn’t understood the language of the patient’s mother, I would not have been able to make the right decision in referring that child for further assessment. However, I wasn’t allowed to ask the patient directly in Urdu. In seeking to obtain an appropriate response for recording purposes, I could only paraphrase my question in English. That was very frustrating!

The process was also time-consuming and expensive. The associated costs—time and money—could have been easily avoided if I had assessed the patient in my primary language. The organization could have asked other bilingual nurses to review the call. In addition, other independent translation agencies could have reviewed and assessed the call, if necessary. However, managers did not act on such suggestions because doing so was against organizational policy. 

Patients like being understood
A journal article I co-authored on the topic presents the findings of a qualitative study of 59 nurses in acute-care hospitals in the UK. Our research indicates that the practice of bilingual nurses providing language concordant care to patients varies depending on the culture of the organization, clinical area, experiences, confidence of the bilingual nurse, and attitudes of nurse colleagues working in the same area. We found that language concordance between nurse and patient facilitates patient-centered care and enhances patient satisfaction.

In addition to improving patient care experience, language concordance enhances the patient’s comfort and conveys a sense of importance and assurance that their concerns have been understood. Nurses contributing to the study suggested that the most appropriate way to ensure language concordant care is to encourage bilingual or multilingual nurses to use their linguistic abilities when providing patient care.

Translation and interpretation policies should be clearly established in each healthcare organization or system, and nurses and other healthcare professionals should be involved in the process. Although the study mentioned here was conducted in the United Kingdom—and thus refers to providing care to patients with limited ability to speak English—dealing with language barriers and providing language concordant care are issues that need to be addressed around the world. 

Parveen Azam Ali, PhD, RN, lecturer and researcher at The University of Sheffield School of Nursing and Midwifery in Sheffield, England, and associate editor, Nursing Open, received the Emerging Researcher Award at the 28th International Nursing Research Congress in Dublin, Ireland.