I recently finished my 2nd clinical block where I was placed at Worcester Provincial Hospital. During this block the majority of patients I encountered had Afrikaans listed as their home language. Afrikaans is my home language as well which allowed me to identify and engage with the patient in a language we were both comfortable in. This lead to the majority of my assessments and treatment sessions to be friction-less. The rest of the patients were either English or Xhosa speaking with at least three of the Xhosa speaking patients, not able to understand a word of English or Afrikaans. The sessions with English speaking patients went no differently than those with Afrikaans patients, as I am fluent and comfortable speaking in both these languages. This allowed me to conduct my subjective and objective assessment, followed by treating and educating the patient, with ease. Being able to converse with patients in their first language builds respect and trust and while improving cross-cultural understanding. All of which are vital components of effective patient-centered health care (Van den Berg, 2016).
However, when it came to the few patients unable to understand English or Afrikaans, my friction-less sessions quickly became troublesome and time consuming. These patient’s verbally expressed themselves in a language I did not understand a word of whilst I asked questions and gave instructions in a language THEY did not understand. During these sessions with patients with different home languages, it became clear that the patients’ attitudes immediately change once they are addressed in the language they are most comfortable with. The Afrikaans and English speaking patients were pleasantly surprised when I was able to conduct the sessions in fluent Afrikaans or English. Thus, in my experience, when a patient is addressed in their home language, their emotional walls crumble and they immediately become more comfortable and adherent. The sessions are more lighthearted and efficient.
In contrast, when I failed to address the Xhosa speaking patients in Xhosa, they immediately became withdrawn and less interested in our sessions. It made me feel unprofessional and less efficient as a physiotherapist, which led to my usually durable enthusiasm to deteriorate. This was confirmed by a study conducted in a Western Cape district hospital where it was established that language barriers negatively influenced the attitude of patients and staff towards each other as well as decreased the quality and satisfaction with care (Van den Berg, 2016). This study also found that Xhosa speaking patients felt inclined to say that they understand what was explained to them even when they did not as they consider it as disrespectful to “disagree with” the health care provider. This inability to communicate with healthcare providers effectively adds to patients’ uncertainty and emotional stress and often prevents them from seeking future health care, resulting in complications of condition/impairment (Van den Berg, 2016).
Complicating matters further, people from different cultural groups describe pain and distress quite differently with regards to culturally-specific terms, expressions, or metaphors can be difficult to navigate in the presence of a language barrier (Meuter, Gallois, Segalowitz, Ryder & Hocking, 2015). Members of the health care system should be aware of how the personal and cultural beliefs of their patients will influence the way they express pain as under-treatment or over-treatment might occur if they are not (Nortjé & Albertyn, 2015). It is clear that cultural competence necessary for developing understanding and respect between healthcare providers and patients. This is especially true in a health care system like South Africa’s where consultations are generally conducted in patients’ second or third language (Van den Berg, 2016).
My only option was to kindly ask one of the Xhosa speaking cleaners, Jenny, to be my interpreter. This was suggested since she is fluent in both English and Xhosa. However, according to Van den Berg, 2016 interpreters tend to impose their own views on consultations, make translation errors and may fill in gaps with their own knowledge. This meant that making use of an interpreter (like Jenny) without a medical background could potentially be dangerous to the patient as precautions regarding surgeries might have been lost in translation. Furthermore, when conveying the details of a diagnosis, treatment or surgery to a patient, it is crucial to do so accurately. As well as the seriousness of conditions, risk factors and contraindications. Failure to do so may have negative or fatal consequences as patients might not adhere to instructions and warnings (Van den Berg, 2016).
Making use of an interpreter made it possible to retrieve all the necessary information I needed for my subjective and objective assessment as well as give instructions to perform certain activities and/or exercises. Some healthcare providers feel that using an interpreter is time-consuming and staff who are constantly asked to perform this role in addition to their other duties, become frustrated (Van den Berg, 2016). I usually needed to first ask administration to dispatch her over the hospital’s intercom which negatively influenced my time management. I also felt guilty for constantly expecting Jenny to abandon her work and obligations to assist me with mine. Even if the interpreting was performed by other medical staff, the efficiency and quality of communication would still depend on the interpreter (Van den Berg, 2016).
My own experience and the literature made it clear that interpreters are not the best solution for the language barrier that continues to largely influence the South African population’s quality of, and access to healthcare services. Another approach to address the language barrier is for healthcare providers to learn to speak the language of their patients. This will lead to a mutual understanding and respect during consultations. However, this approach has its own challenges considering the demands of the busy healthcare sector/practice. Miscommunication is also more likely to occur when healthcare providers use an inadequately mastered second language (Van den Berg, 2016).
Code switching could also be a useful alternative to acquiring a second or third language. Code switching refers to a linguistic phenomenon where the speaker changes between two languages in a single sentence or conversation (Van den Berg, 2016). This means the healthcare provider still conducts the consultation in the language they are most comfortable with, but acquires some essential terms and phrases in the patient’s home language aid in retrieving necessary information and giving instructions. Still, much room remains for misunderstanding (Van den Berg, 2016). Personally, I feel that all South African universities should incorporate a compulsory 3rd language into the curriculum, especially if the field of study is medicine. Even if the added module only focuses on general terms and phrases.
It is clear that culturally sensitive pain assessment should be part of every treatment plan, as pain is subjective and influenced by cultural factors. The inability to understand a patient will have a negative impact on the health care worker’s ability to be empathetic and approachable as well as giving effective patient education. Whereas the inability of a patient to be understood by their healthcare provider will lead to patient confusion and dissatisfaction. The use of interpreters have been a viable solution to this complication thus far, but it cannot be considered as sufficient. This highlights the alarming need interdisciplinary cooperation between language practitioners and healthcare professionals to find viable solutions to the existing communication challenges within the culture rich South African population, in order to honor the right of every citizen to fair health care.
Reference list
Meuter, R., Gallois, C., Segalowitz, N., Ryder, A., & Hocking, J. (2015). Overcoming language barriers in healthcare: A protocol for investigating safe and effective communication when patients or clinicians use a second language. BMC Health Services Research, 15(1). doi: 10.1186/s12913-015-1024-8
Nortjé, N., & Albertyn, R. (2015). The cultural language of pain: a South African study. South African Family Practice, 57(1), 24-27. doi: 10.1080/20786190.2014.977034
Van den Berg, V. (2016). Still lost in translation: language barriers in South African health care remain. South African Family Practice, 58(6), 229-231. doi: 10.1080/20786190.2016.1223795