Effective communication is important in healthcare given that health professionals deal directly with patients (Divi et al, 2007; Houle 2010). Patient care is compromised when healthcare providers face direct communication failures with patients because of language discord (Schyve, 2007).
Kuwait is home to approximately 2 million expatriates, making up 70% of its population. This includes Arab and Asian expatriates: Arabs (Egyptian, Lebanese, Syrian, Jordanian, Iraqi, Yemeni); South Asians (Indian, Bangladeshi, Pakistani, Nepali and Sri Lankan); and others (Filipino, Ethiopian, Indonesian, American, Iranian and Europeans) (Central Intelligence Agency, 2019). The rapid migration of multicultural people into the State of Kuwait could lead to communication difficulties for many migrants who do not share a common language.
The emergency medical services (EMS) of Kuwait, within the State's national ambulance service, employs diverse nationalities who work in the paramedical field. These include Arabs and Asians from a variety of backgrounds in education, culture and language. The English language is widely spoken; however it is the second language after Arabic. These challenges therefore have an impact on patients as well as prehospital care providers, namely the emergency medical technicians (EMTs) and paramedics. These issues are crucial in the prehospital setting where the delivery of care is time-limited, especially in emergency situations and where communication is a matter of life or death, or safety versus risk (Pyke, 2010).
The gap in understanding the effects of language barrier in prehospital care has yet to be addressed (Tate, 2015). Language discord affects access to care and presents difficulties in patient and staff communication, while decreasing satisfaction and the value of care (Narayan, 2013). Language-efficient healthcare practice is central to high-quality care. The Joint Commission, a US-based healthcare accrediting body, carried out a cross-sectional study of hospitals delivering healthcare to culturally and linguistically diverse patients. They revealed that effective communication with patients is critical to the safety and quality of care, and poor communication is synonymous with dangerous patient outcomes (Wilson-Stronks and Galvez, 2007). Failure in communication is the primary root cause of patient harm (Schyve, 2007).
The significance and value of a common language for providing timely, safe and optimal care to patients is widely known (Divi et al, 2007; Schyve, 2007). Competent communication is essential for delivering high-quality, safe, and effective patient care (Pyke, 2010).
Methods
Aim
The aim of the present study was to provide prehospital care providers (EMTs and paramedics) with an opportunity to express their views and experiences of the lack of a common language in which they can communicate with patients, and to gain insight into the challenges they face in a prehospital setting in Kuwait.
Study design
An exploratory case study is described to reflect the common characteristics among participants' practices in order to provide a rich account of experiences and events. Focus group interviews were used as the data-gathering tool.
One of the qualities specific to focus-group interviews is its group dynamic. Three focus groups were brought together for a ‘carefully planned series of discussions designed to obtain perceptions on a defined area of interest in a permissive, non-threatening environment’ (Kreuger and Casey, 2009: 5). These were effective in eliciting data and in generating a broad overview of the issues which EMTs and paramedics encounter. This format also enabled group members to describe their experiences about a topic in greater depth, through shared viewpoints, generating insights and information, and discovering new ideas.
A semi-structured topic guide was used, allowing flexibility in the questions asked by the researcher. All respondents were asked predetermined questions, which were ordered as appropriate to allow respondents to talk about the topic using their own words (Matthews and Ross, 2010). The topic guide allowed for consistency in questioning, which was vital to achieving data saturation (Kreuger and Casey, 2009).
Respondents
Kuwait EMS has a total of 2076 employees distributed across 67 ambulance stations, where 59.3% of employees speak Arabic as the first language and 40.7% are foreign nationals whose primary language is one other than Arabic. The majority of the respondents in this study were foreign nationals, although Arab nationals, who do not speak English were also invited to participate as they provide assistance to foreign nationals who cannot communicate in Arabic (Department of Emergency Medical Services, 2016). All participants were male with varied durations of experience, ranging from 1–8 years in practice.
Purposive sampling (Moser and Korstjens, 2017) was used whereby respondents in the three main ambulance stations in Kuwait (Al Adan, Mubarak, Al Amiri) were identified through the demographic database of EMTs and paramedics, and where the greatest number of patient encounters were recorded. Access and permission were granted by the head of department within each station.
Respondents were selected based on the belief that their knowledge, expertise and varied experiences would generate insight and information relative to the research topic. This included non-Arabic speaking EMTs and paramedics whose language ability is limited irrespective of the years of experience, and where the majority of their patients are primarily Arabic-speaking and whose English comprehension is limited. However, to increase the inclusiveness of respondents and cater to linguistically diverse populations (relative to the subject matter and to consider the linguistic competence of Kuwait EMS where almost 60% speak Arabic as their first language), Arabs who do not understand and cannot communicate in English or other languages were also invited to participate.
Data were collected until saturation was reached, whereby no new concepts or dimensions for categories were identified (Kreuger and Casey, 2009). A total of three focus groups with 22 participants were conducted (n=6; n=7; and n=9). The ideal number of respondents in a focus group is 6–9 up to a maximum of 12 (Wilson-Stronks and Galvez, 2007); over 12 may be difficult to control and may be challenging (Bowen, 2008).
Procedure
Ethics approval was sought from the Dasman Diabetes Institute Kuwait and the Department of Emergency Medical Services of the Ministry of Health Kuwait. The ethical principles from the Belmont Report (The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1979) were followed and applied. Respondents were invited via email, where they were provided with details about the study aims, the extent of their participation, and the respondents' role in the focus group. Informed consent was taken from all respondents after ensuring a full understanding of the study. Respondents could withdraw their participation from the research at any time without prejudice.
As this is the first study of its kind to be carried out in the prehospital setting in Kuwait, a pilot study (Connelly, 2008) was conducted with EMTs who would not be participating in the study, but who likely shared similar characteristics. This allowed the interview guide to be tested for consistency and accuracy, as well as the exploration of any issues prior to the full-scale research being carried out. However, no changes were made to the study as a result of the pilot.
Each focus group took place during respondents' working hours; a written agreement from the ambulance station head of department was therefore obtained to allow all respondents to take part without interruption and within the allocated time frame. Each interview lasted approximately 60 minutes.
Data analysis
Analysis started as soon as data were collected as the exploration largely depends on the interpretation of raw data, field notes and recorded transcripts. The audio-recorded interviews were transcribed verbatim. This method is considered a key phase in data analysis of interpretative qualitative methodology (Mack et al, 2005). Thematic analysis, a foundational method for qualitative analysis, was carried out whereby data were coded and categorised to identify emerging themes (Braun and Clark, 2008; Saldana, 2009).
Data triangulation was undertaken by a secondary coder. To address matters of factual accuracy and appropriateness of the analysed data, respondents validated the findings. This also substantiates the researcher's interpretation and recognises the prejudices that might present during the process of interpretation (Denscomb, 2010). In order to reduce researcher bias, reflexivity was ensured whereby the researcher reflected on the ‘self’ in order to remain as objective as possible (Barry et al, 1999). To confirm credibility of data interpretation, a peer debriefing method was implemented through which data were secondarily examined by an unbiased source (Lincoln and Guba, 1985). Subsequent analyses were contrasted to ensure compatible themes, and reduce likelihood of researcher partiality.
Findings
Findings from the three focus groups were combined, resulting in three main themes:
Direct effect on healthcare delivery
Language barrier had varying effects on the delivery of care where prehospital care providers were expected to give utmost care to their patients without delay. Time was seen as a significant factor for providing direct patient care, which resulted in delayed assessment, treatment and limited medical management of the patient on scene.
Respondents raised an ‘unpleasant patient experience’ as an associated patient response to the language barrier. This was supported by respondents' observations, which expressed negative reactions from patients when care was interrupted. ‘Misdiagnosis’ was also perceived to be a direct consequence of language barrier.
‘Since my Arabic language is weak, I had to take more time in explaining to my patients the things I am about to do like if I have to take the blood sugar or BP [blood pressure] and when if it's an emergency, I can't really act that fast enough.’
‘When I can't understand my patient, I had to take time assessing his/her condition because I want to be sure that I am right before I manage his condition.’
‘Since my patient won't speak to me because he doesn't speak in English, I just relied on my vital signs and it was normal, so my diagnosis was hysterical case but after a while he vomited twice and it was actually gastrointestinal problem. I thought he was just acting out.’
‘I thought my patient was only complaining of dizziness since we didn't understand much but I later found out that it was low blood sugar when one of the relatives mentioned that he has history of diabetes and after checking his blood sugar, it was indeed having low blood sugar. When I try to repeat what my patient was trying to say, sometimes she yells at me because my Arabic is bad and she wants help quickly.’
Professional implications
As a direct consequence of the language disparity among patients, respondents identified the need to improve their practice through the use of non-verbal communication techniques to enhance their verbal messages. Use of technology directly empowered some prehospital care providers to bridge communication gaps in their professional practice. This was a strong incentive for the respondents to learn a language through formal or non-formal training as there was a dependency in terms of the need to ask for help with language translation from a colleague, patient's family member or a bystander while providing care.
‘Well I have tried to use Google translate like I let my patient speak in Arabic and I recorded his voice then the Google translate application translated it to me in English.’
‘I notice that sometimes the relatives or patient would directly talk to my partner who speaks Arabic, especially if they don't’ speak English that much and I would ask my partner to translate it to me so I can proceed.’
‘I never really thought that I've had to go to an Arabic class until one day my patient already shouted at me because it gives her added discomfort because I was a bit slow since we didn't understand each other much.’
‘Sometimes, my partner is good (ahh) he knows Arabic… every single word so before transporting the patient, if the patient is conscious, he explains everything and translates to me then according to that I would give my management.’
‘Oftentimes I would use my hands and facial expressions to enhance my understanding, especially if some Arabic words are not very clear to me. Sometimes, words are not enough and their face would tell you that.’
Personal implications
Some respondents linked ‘distorted’ communication with a negative physiologic response, notably stress and exhaustion. The prehospital care provider's inability to communicate effectively led to declining efficiency, which caused a significant regression. The communication gap resulted in social and emotional disturbances including frustration, negative patient-provider trust and an altered sense of self-confidence.
‘…you would feel that you are not doing your best if you can't communicate well like in my case my assessment was delayed because I had to take more time talking to my patient just to make sure we understand each other.’
‘You can't really build that trust initially which is very important for us.’
‘…and you would come to a point that you are stressed out, you have a headache, and tired.’
‘Whenever I don't understand my patient, I feel I am not confident to do the task at hand.’
Discussion
The findings of this small-scale study show that language barrier has direct implications for the delivery of care, which affected EMTs' and paramedics' personal and professional practice.
While a delay in patient management is a direct consequence of language barrier, and the ‘on-scene time’ during immediate patient management was longer with patients who have a lower English proficiency compared with those patients who were more proficient (Weiss et al, 2015), there was no reported clinical significance in this prehospital setting. However, misdiagnoses of a patient's illness resulted from the EMT's misunderstanding of patients' verbal messages. This is consistent with Timmins' (2002) and Ratner's (2001) findings whereby negative outcomes of language barrier on provider-patient interaction, and misdiagnoses, posed a threat to patient safety (Flores et al, 2000; Bowen, 2004; Gadon et al, 2007).
The unfavourable experiences of discordant communication with patients led respondents to learn the Arabic language and to improve non-verbal communication techniques such as eye contact, facial expression and gestures to enhance verbal responses. Physicians improving their communication has been shown to result in better patient adherence, whereas adopting the language and being more willing to communicate with patients in their local language has resulted in increased patient satisfaction (Mazor et al, 2002; Zolnierek and DiMatteo, 2009; Khan et al, 2011). Patients' non-verbal communication may provide EMTs with current emotional state and unequivocal information (Włoszczak-Szubzda et al, 2013). In the longer term, the additional benefits of training health professionals may help to establish and build trust, which in turn can have a positive impact on the therapeutic relationship (Berthiaume and Pascale, 2013); patient adherence (Zolnierek and DiMatteo, 2009); and patient satisfaction rates (Mazor et al, 2002).
The role of technology and the use of Google translate, downloadable translator applications and translator devices to enhance communication, demonstrated benefits to EMTs on scene, especially in non-urgent cases. The challenges and issues experienced by EMTs while using these services on scene, such as accuracy of interpretation, are worth exploring. One hospital study validated that Google translate has issues with accuracy in medical translation, and found it to be of limited usefulness for doctor-patient communication (Davies, 2014).
Respondents reported that, at times, they were dependent on a colleague, a family member of the patient, or a bystander on the scene to fill gaps in communication. Family members as interpreters can potentially hinder a patient's autonomy and lead to the omission or refusal to communicate all of the relevant information, possibly for cultural reasons, as a result of discomfort or as a way of protecting the patient (Drennan, 1996; Vissandjée et al, 1998). However, ad-hoc interpreters on scene, such as a family member or bystander, lessen the need to hire an interpreter service, which is not feasible in an emergency prehospital setting. Furthermore, having a family member interpret eliminates the need to establish rapport or trust with the patient, thus improving satisfaction (Baker et al, 1996; Baldonado et al, 1998; Kuo and Fagan, 1999; Bollenbacher et al, 2000; Lee et al, 2002).
In the present study, ineffective communication negatively affected the socio-emotional attitude of respondents. Declining efficiency levels and negative socio-emotional impact were perceived as physiologic responses to language barrier. Discordant communication caused stress for the EMTs resulting in physical and psychological exhaustion. When there is reduced understanding because of flawed communication, whether in general communication, history-taking, or comfort and pain management among health professionals and their patients, it resulted in stress (Bernard et al, 2006). Exhaustion as a result of stress resulted in one respondent being less efficient:
‘…once you are drained you become less efficient’
This could potentially lead to the loss of ability to deliver or produce desired results without compromising resources, time, or energy (Sanchez-Campos, 2004; Schlemmer and Mash, 2006).
Frustration emerged with the perceived inability to establish trust, and an altered level of confidence. Frustration, as a reaction towards language barrier, has been widely experienced among health professionals where first responders become frustrated when they cannot understand their patients (Pressman et al, 2011). Establishing a relationship and building trust with patients was deemed an important aspect of communication in terms of developing self-confidence (Pyke, 2010; Pressman et al, 2011).
Conclusion
In contrast with previous research, the current study has added meaning to the effect of language barrier on EMTs and paramedics, and its implications for practice, in a prehospital setting in Kuwait.
This small-scale case study was effective in obtaining the experiences of prehospital care providers within a practice setting. The findings may not be generalisable to similar populations or to all areas of medicine and may not be representative, typical or repeatable. However, they demonstrate the case in terms of its complexity and its totality, as well as its setting.
The personal and professional implications for EMTs and paramedics, and the direct effects on healthcare delivery, are vital and distinct sources of information, as well as knowledge that could serve to influence current and future practice. They bring to light EMS system deficiencies in order to improve EMS healthcare delivery in Kuwait.
Recommendations for the EMS of Kuwait, as a result of this study, should focus on providing language acquisition and training for prehospital care providers and exploring the usefulness and limitations of communication assistive devices. In addition, the role of technology towards enhancing communication between patient and care provider should be considered.