Why is inclusive intercultural communication important in healthcare?

Effective communication between healthcare providers and non-native English speaking patients is essential for accurate diagnosis and treatment. Of course, communication also plays a significant role in patient safety. Clear and concise communication among healthcare team members helps prevent errors, such as medication mix-ups or misinterpretation of instructions. In addition, communication helps build trust and rapport between healthcare providers and patients. When patients feel heard, understood and respected, they are more likely to actively participate in their own care and follow treatment plans.

What steps can we take to make our language easier to understand?

There are many ways we can adjust our language, but below are four good starting points:

1. Add pauses when you speak

Slow down and, more importantly, add pauses when you’re speaking so that your patient has time to process what you’re saying. If English is not your patient’s first language, it may take them longer to digest what is being said, work out their response and then find the right words in English to reply. Although we often feel uncomfortable with silences in our conversation, these pauses can be critical to a patient’s understanding. Adding pauses also supports active listening and will help you respond appropriately to your patient’s language level. On a final point, including pauses can make your accent easier to understand.

2. Reduce idiomatic language and paraphrase when necessary

There are approximately 25,000 idioms in the English language! This is why we have to be mindful when we use them with non-native English speaking patients as it’s impossible to know which ones they will know. Expressions such as ‘nip it in the bud’, ‘bear with me’ and ‘feeling out of sorts’ can leave your patient confused, adding to any potential stress. It’s unrealistic to stop using idiomatic language completely but try to paraphrase where possible; for example, I hear you’re a bit under the weather, feeling unwell.

3. Avoid (or at least explain) acronyms and abbreviations

Healthcare is full of specialist terminology and acronyms. These are particularly difficult for patients who speak English as an additional language. Even everyday terms such as ‘GP’ and ‘A&E’ may be unfamiliar as well as non-medical acronyms such as ASAP. The fact that certain letters can sound very similar, for example ‘p’ and ‘b’ or ‘f’ and ‘s’, compounds the problem. So when you use them for the first time, explain what you mean. If there are numerous terms associated with a particular health condition or treatment, consider giving your patient a written glossary of terms.

4. Use direct questions

The language we use is often very indirect and this is particularly true of how we structure questions and instructions. We instinctively add unnecessary language in order to ‘soften’ our request or to come across as friendly and polite. For example, we may say "I was wondering whether we could have a quick chat about your medication?" rather than the much more straightforward "Could we talk about your medication?" It’s important to keep questions short, simple and direct. You can create a friendly manner through facial expressions and using your patient’s name.

Call for action

Awareness of how we can all adapt our language to better meet patient’s needs is key. While health organisations regularly make use of translators and interpreters, many are unaware of the intercultural communication training that members of staff can take part in to support and enhance their communication skills. By making health organisations more language aware, staff can start to implement simple strategies that will improve patient safety and optimise their healthcare experience.

Related reading on the hub:

• Accessible patient information: a key element of informed consent (by Julie Smith)
• CardMedic: Empowering staff and patients to communicate across any barrier

1. Utilising patient feedback.
2. Information as a tool for patient empowerment.
3. Furthering access to medical records.
4. Promoting patient engagement by addressing power differentials.
5. Building trust.

When Vincent Van Gogh painted the empty chairs, it was his purpose to distinguish the two chairs; his and that of Gaugin’s. Van Gogh’s chair is painted to be less mystical; straight backed and with no armrests, made of plain unpolished wood. Gauguin's chair was a more ornate and luxurious piece of furniture, with a high back and a carved seat. The chairs were a reflection of the two artist’s personalities and their relationship with each other. 

While visiting the Van Gogh Alive festival in Adelaide, these paintings of Van Gogh’s chairs stood out at me because I have always found it uncomfortable when I had to point to a simple chair (a backless stool or a plastic chair without armrests) to sit down for my patient, while I was sitting in an imposing high back black leather executive chair with padded armrests, lumbar support, back and head rest adjustment and a swivel base. 

The image below is an AI generated image. I used the prompt: “painting of a doctor's chair and a patient's chair in a consultation room, painted in the style of Van Gogh”. Guess which chair is the patient’s chair? The concept is so ingrained in society that even generative AI and natural language processing models take it for granted that the patient should be seated in the smaller chair. 

Since early history, elaborate chairs have been used as a symbol of power by the higher strata of the society – kings, priests and the like – and the simpler backless version of the chair, the stool, is used primarily by the lower strata. Authority, domination and power is what come ultimately to mind when one thinks of chairs (Danto, 1987).

The design and the use of the chair is deliberate and the the symbolism is still evident today. It is no accident that the high-ranking officials are given the best and expensive chairs positioned at the front, while others sit in less conspicuous or cheaper ones. It is designed to show power and status. 

Given the power imbalance between the doctor and the patient, with the seemingly powerful situation the doctor is given in the relationship due to the deference to expertise, the simple chair the patient sits on only acts to reinforce the power imbalance. 

As it is, several barriers exist that make patients hard to speak up, even where patients are well-informed and well educated. Many patients feel they can’t participate in shared decision-making, and the power imbalances are a key barrier even if patients have the knowledge (Joseph-Williams, 2014). 

Because patients must have equal power in the relationship as a partner in care, it is time we do not make this distinction in the design of the clinical environment. The patient is an equal partner in the therapeutic relationship and is very much an expert in the lived experience of their illness. 

We cannot imagine two leaders of a company being shown two very different types of chairs – one simple and one expensive – when seated to discuss and finalise on an agreement. 

Why must it be any different for the doctor and the patient? 

• Most people had positive experiences when dealing with healthcare staff but overall coordination of care and information about it was lacking
• Many people said their health and needs affected their mental health and made them feel lonely
• Many people weren’t involved in decisions about care and treatment and were sceptical about patients becoming partners in future
• Many people struggled to contact the service they needed and faced long waits for an appointment
• Some people struggled to get any help or support at all for their health and care needs
• Remote consultations work for some people, but more said they preferred face-to-face appointments

• 60% of those who died from Covid-19 in the first year of the pandemic were disabled. The health inequalities disabled people already faced were made worse by the pandemic and a decade of austerity. In this context, it’s vitally important to include disabled people in designing and planning health and care system responses.
• Health and care services need to understand the broad diversity of disabled people’s identities and experiences, and adopt a social model approach to disability, understanding that people are disabled by barriers in society, rather than by impairments or health conditions.
• Health and care professionals need to value disabled people’s expertise through properly recognising the value of lived experience and ensure disabled people’s voices are central to any plans right from the start.
• Disabled health and care staff are potential partners in this work, with their perspectives of both using and delivering services.
• Disabled people’s organisations (DPOs) can strengthen their impact by working with other local DPOs and user-led organisations, understanding which parts of health and care systems they can best influence, and supporting health and care organisations to meaningfully engage with disabled people.
• Both health and care organisations and DPOs need to improve their understanding of how people’s multiple identities shape their experiences, and embrace diversity of voices, opinions and challenges as an opportunity to think differently.
• Ensuring disabled people’s voices are heard requires constant attention. While there are some examples of good practice, we heard many stories we heard where involvement wasn’t happening or felt tokenistic.