1.
INTRODUCTION
1.1 Introduction
Language is a set of traditional spoken, manual (signed), or written symbols
through which humans express themselves as members of a social group and
participants in its culture. Language serves several tasks, including
communication, identity expression, play, imaginative expression, and
emotional release (Robins and Crystal, 2025). Since there are so many distinct idioms, it
is inevitable that people from various languages and cultures will need to speak with one
another. According to Jackson (2020), experts characterise intercultural communication as
"the exchange of information between individuals who are not culturally similar." Intercultural
communication can be hampered by a "language barrier," which is characterised by terms or
phrases that the other party may not comprehend, which can result in mistakes and
miscommunication. A dialect that is unfamiliar to the other person or jargon that others are
unfamiliar with can also cause this barrier, in addition to the usage of a different language
(Communication, 2015).
As global migration continues to rise, nations across the globe are encountering growing
challenges related to cultural diversity in their populations. In a multicultural society, effective
communication is essential yet difficult, particularly in healthcare. The Nursing and Midwifery
Council (NMC) mandates nurses to care for patients from various ethnic origins while
considering their specific needs. This is specified in the Code of Conduct's 'Priority People'
section (NMC, 2018). To deliver holistic and culturally sensitive care to an increasingly varied
population, nurses must be able to effectively communicate with patients from various cultural
backgrounds (Mosed & Periord, 2021). The NMC (2018) Code of Conduct highlights the
significance of clear and effective communication.
But what is communication?
The Oxford English Dictionary (OED) defines communication as 'the transmission or exchange
of information, knowledge, or ideas, by means of speech, writing, mechanical or electronic
media' (OED, 2019).
According to Richard G. Jones Jr. (2013), communication is the process of generating
meaning by sending and receiving verbal and nonverbal signals influenced by several
contexts.
There are several types of communication. Verbal communication: As the name implies, is the
use of words to convey thoughts, emotions, and ideas. You can accomplish this via speaking
or writing. Furthermore, because it is rapid, it is one of the most fundamental and often utilised
modes of communication.
Verbal communication consists of oral communication, done using one’s mouth and voice.
Written communication, on the other hand, involves conveying messages through text, email,
or letters. Unlike spoken communication, which uses tone and volume to express emotion,
written communication relies on punctuation and formatting to convey emotional cues (College
of Contract Management, 2024).
Nonverbal communication: When talking about communication abilities, we always think of
verbal communication skills. However, nonverbal communication is equally vital, if not more
so, for effective communication. According to a study published in the British Journal of
General Practice, patients respond better to nonverbal communicative behaviours than verbal
communication behaviours (Little et al.).
According to Mehrabian's communication theory, words account for 7% of all communication,
tone, and voice 38%, and body language 55% (Mehrabian, 1972).
Nonverbal communication includes various forms such as facial expressions, which
universally convey emotions like happiness or anger. Body posture and movement also reveal
much about a person’s feelings and confidence. Gestures are common but can vary in
meaning across cultures, making context important. Eye contact plays a key role in expressing
interest or emotion and maintaining conversation flow. Touch, whether a handshake or hug,
can communicate warmth, control, or formality. Personal space reflects comfort levels and
varies by culture and relationship. Lastly, voice tone and pace add meaning beyond spoken
words, revealing emotions like sarcasm, affection, or tension (Smith, Robinson & Segal,
2025).
1.2 Communication in health care settings
Effective communication between patients and healthcare professionals is crucial for
diagnosis and treatment (López et al., 2015). It can help prevent errors and misunderstandings
that could endanger the patient's life (Meuter et al., 2015).
In the relationship between patients and healthcare operators, the communication style of the
operator is crucial. According to literature, assertive communication reduces patient anxiety
and increases their willingness to attend treatments, whereas dominant or imperative
communication, with promises to improve, reduces patient compliance (Vogel et al., 2018).
The use of specialised medical terms by healthcare operators can make communication
ineffective. According to Bittner et al.'s study, users often do not fully comprehend medical
information due to the medical and technical terminology used. Additionally, patients often
associate medical and scientific terms with negative connotations. However, doctors often use
technical terms that patients do not understand and overestimate their communication skills
(Bittner et al., 2016).
1.3 Language barrier
Effective communication involves exchanging ideas, thoughts, knowledge, and information to
ensure that the message's purpose or intention is met in the best way possible (Could, 2020).
Effective communication includes clear, correct, complete, and precise messages,
trustworthiness, consideration for the recipient's attention, language, knowledge, instruction
and physical restrictions, and courtesy from the sender. The obstacles to effective
communication include:
1. Using unfamiliar or complicated terms.
2. Emotional barriers, and taboo topics.
3. A lack of attention, interest, disruption, or distraction for the recipient.
4. Differences in perception and perspective.
5. Physical disabilities such as hearing or language difficulties.
6. Physical barriers to nonverbal communication.
7. Linguistic differences and the difficulty of understanding unfamiliar accents.
8. Expectations and biases that may lead to incorrect hypotheses or stereotypes.
9. Cultural differences (Could 2020).
The probable causes of language barriers in the healthcare setting are numerous.
The increasing number of migrant patients and personnel from different countries increases
the likelihood of communication errors between them (Meuter et al., 2015).
Nurses, as the first point of contact with patients in the healthcare system, can improve patient
safety and satisfaction by overcoming linguistic and cultural barriers (Gerchow et al., 2021).
Although interpreters can be used in healthcare to reduce communication gaps, many lack
medical training and may not understand the terms used (Azam et al., 2018).
Background
Language problems provide a huge challenge in healthcare, as the author discovered during
a placement on a hospital ward. While shadowing a nurse, the author came across an old
patient of Punjabi descent who could not understand, speak, or read English. Communication
with the patient was reliant on the availability of multilingual staff workers who understood her
language. However, due to changing shifts and irregular staffing, this aid was not always
accessible.
During visiting hours, usually in the evenings, the patient's relatives would help with
communication, but for most of the day, staff struggled to interact effectively with her. This lack
of regular communication presented safety issues and resulted in many of the patient's
requirements being unmet. The patient had mobility limitations and needed help with personal
hygiene. She did not utilise the call bell to ask for help, and staff often became aware of her
discomfort through observation. Attempts to detect her requirements usually devolved into
guesswork, occasionally culminating in continence episodes in bed or in a chair. Out of
irritation, the patient once tried to walk to the toilet unassisted, placing herself in danger due
to her limited mobility.
Furthermore, the patient had been provided PRN (as-required) pain treatment, but nurses
were frequently unable to tell when she was in pain. Even when specifically questioned, she
was unable to react effectively due to her insufficient knowledge of English.
Consequently, her pain may have gone undetected and unaddressed, potentially affecting her
wellbeing, as language and cultural differences can lead to miscommunication that
significantly impacts patient safety and health outcomes (Hamilton & Woodward-Kron, 2010).
The NHS Person-centred Approach Framework prioritises tailoring care to everyone's values,
preferences, and requirements. In this scenario, a lack of effective communication directly
contradicted those principles, preventing nurses from identifying or meeting the patient's pain
management and personal hygiene needs (NHS, 2017).
Furthermore, the Equality Act 2010 imposes a legal obligation on healthcare providers to
address inequities, including those caused by language difficulties. Failure to implement
strategies to address these barriers jeopardises equitable care delivery. In this situation, the
patient's unmet demands point to a systemic issue that can perpetuate inequities in health
outcomes. (Equality Act of 2010).
Immigration statistics
The high rate of global migration contributes to a multicultural society and linguistic diversity.
According to the International Organization for Migration (IOM) data, there were 281 million
international migrants in 2020, accounting for 3.6% of the global population, compared to
272 million (or 3.5%) in 2019. Furthermore, 89.4 million people have experienced global
displacement in 2020, compared to 84.8% in 2019(Migration, 2022).
According to the Office for National Statistics' (ONS) 2021 Census, there were 10.0 million
usual residents in England and Wales who were born outside the UK, accounting for 16.8%
of the total population. This is an increase from 7.5 million (13.4%) in 2011.
In 2021, Germany (439 000 people, or 19% of all immigrants from non-EU countries) and
Spain (421 000, or 19%) were the most popular destinations for immigrants from outside the
EU, followed by Italy (248 000, or 11%) and France (238 000, or 11%). In 2021, those who
migrated to these four EU nations accounted for 60% of all immigrants from non-EU countries
(Eurostat, 2023).
Going back to the UK 2021 census data, Polish (1.1%, 591,000) was the most prevalent
main language among individuals who did not speak English as their first language in
England. At the regional level, the East Midlands had the largest percentage of persons who
spoke Polish as their primary language (1.5%, 71,000). The percentage of persons who
speak Polish as their first language varies by local authority, from 0.1% (100) in Castle Point
to 5.7% (4,000) in Boston (ONS, 2021).
The next most common main language in England was Romanian (0.9%, 466,000). The region
with the highest percentage of people who reported Romanian as a main language was
London (1.9%, 159,000). In particular, the local authority of Harrow had the highest percentage
of its population reporting Romanian as a main language (7.5%, 19,000) (ONS, 2021) .
The third and fourth most common languages, excluding English, both originate from South
Asia: Panjabi (sometimes spelt Punjabi) and Urdu. They are both widely spoken languages in
India and Pakistan, as well as elsewhere in South Asia. In England, the highest percentage of
people that had Panjabi as a main language was in the West Midlands (1.4%, 83,000).
Wolverhampton was the local authority with the largest percentage of people with Panjabi as
a main language (6.5%, 17,000). The English region with the overall largest proportion of
people who had Urdu as a main language was the Northwest (0.8%, 59,000). However,
Slough in the Southeast was the local authority with the largest proportion (4.3%, 7,000) (ONS,
2021).
People who did not declare English as their primary language (English or Welsh in Wales)
were asked to rate their English proficiency (8.9%, or 5.1 million). Out of those 5.1 million
people, 43.9% (2.3 million) could speak English very well, 35.8% (1.8 million) could speak
English well, 17.1% (880,000) could not speak English well, and 3.1% (161,000) could not
speak English at all (ONS, 2021).
Aim of the project
The researcher's drive to address this matter originates not only from its importance as a real
and reoccurring issue in healthcare, but also from its personal significance to him as an
immigrant who has lived in England for the past eight years. As a future nurse, the researcher
is likely to face similar obstacles in practice. As a result, studying this phenomenon is critical
not only for gaining a better understanding of it, but also for determining the most successful
ways for dealing with it. And in accordance with the nursing and midwifery code (NMC, 2018)
which encourages nurses to be proactive in learning evidence-based treatments and
procedures for better care delivery.
The phenomenon of linguistic barriers exists and is a problem in healthcare assistance
because patients who do not speak or understand the native language face differences in
greetings and treatment, which results in lower quality and from which they receive worse care
(Espinoza & Derrington, 2021).
Therefore, it is necessary that there be established, standardised, and effective measures that
are backed by evidence of efficacy in order to address this issue that is slowly becoming worse
in the sanitation sector. Degrie et al. provide a more comprehensive perspective on culturally
sensitive aids in which patients are treated in a holistic manner while maintaining their dignity
(Degrie et al., 2017). The NMC code and Department of Health and Social Cares’ NHS
constitution for England emphasises that nurses do treat patients with respect and maintain
their dignity (NMC,2018), (NHS, 2012).
Language barriers might affect foreign users, patients with diverse abilities (e.g., autistic, deaf,
mute), and elderly patients who only speak one dialect. This analysis includes foreign adults
who do not speak or understand the host country's language.
This study aims to investigate the effects of the language barrier on both patients and nurses.
Finally, the strategies used in literature to restrict or overcome the detrimental effects of
linguistic barriers will be discussed, along with the pros and downsides.
Methods
Objective
The purpose of this study is to:
●Describe the effects that a language barrier has on patients and healthcare staff.
● Determine potential strategies to improve communication. It considers the linguistic barrier
resulting from the use of different languages between healthcare professionals and foreign
adult patients.
Questions of the research
1. How can language barriers in healthcare settings impact patient health outcomes and
nurse practice?
2. How successful are current efforts for addressing language barriers in patient care?
Databases consulted
The research material was selected through the consultation of the electronic databases
Pubmed, Cinahl and Scopus, in the period between October 2024 and April 2025.
Keywords and search strategies
The PIO method (Tables I and II) was used to formulate the keywords starting from the
search questions.
Search strings
After identifying the keywords related to the search queries, the search strings used for each
database were created,
as reported in Tables IV and V. These keywords were used in combination with the Boolean
operators "AND" and "OR".
The consultation of documents in digital format was made available by the University of
Wolverhampton Library online database service.
Table I: PIO relating to the first question
PIO KEYWORDS
P Patients and nurses in healthcare settings.
I Presence of language barriers in communication.
O
Impact on patient health outcomes and nursing practice.
Table II: Second question PIO
PIO KEYWORDS
P Patients and healthcare providers in clinical settings.
I Current efforts or strategies to address language barriers.
O Success or effectiveness in improving language barriers and patient care
Table III: Search strings related to the first question
Database Strings Results Selected Date and
Articles Time
Accessed
1 Scopus ("language barriers" AND "patient 19 3 25/01/2025
care") AND ("nursing practice" OR at 15:39
"nurse communication") AND
("adverse outcomes" OR "patient
safety")
2 Cinahl ("language barriers" AND "patient 15 1 19/12/2024
care") AND ("nursing practice" OR at 12:20
"nurse communication") AND
("adverse outcomes" OR "patient
safety")
3 PubMed ("language barriers" OR "limited 51 4 15/02/2025
English proficiency") AND at 16:45
("healthcare" OR "hospital" OR
"clinical setting") AND ("patient
outcomes" OR "health outcomes")
AND ("nurses" OR "nursing practice
Table IV: Search strings related to second question
Database Strings Results Selected Date and
Articles Time
Accessed
1 Scopus ("language barriers" AND "patient 84 3 28/01/2025
care") AND ("intervention" OR at 19:05
"strategy" OR "solution") AND
("effectiveness" OR "outcomes"
OR "evaluation")
2 Cinahl ("communication tools" OR 38 0 21/12/2024
"interpreter services" OR at 18:27
"translation services") AND
("language barriers") AND
("healthcare" OR "clinical
setting") AND ("success" OR
"impact" OR "evaluation")
3 PubMed ("language barriers" AND "patient 165 6 11/02/2025
care") AND ("intervention" OR at 20:37
"strategy" OR "solution") AND
("effectiveness" OR "outcomes"
OR "evaluation")
Date limits
Studies published in the last ten years (from 2012 to 2025), available in full text or open
access, and published exclusively in English (Table VI) were taken into consideration.
Inclusion and exclusion criteria
To carry out the research, the inclusion and exclusion criteria of the studies were first
clarified (Table VII). The search strings were then created, and the potentially relevant
studies were found through a first analysis of the title and abstract.
Table IV: Limits inserted for the research.
Database Limits inserted
Scopus -Articles published between 2012 and 2025
-Articles published in English
- Open access articles
Cinahl -Articles published between 2012 and 2025
-Articles published in English
-Full text articles
PubMed -Articles published between 2012 and 2025
-Articles published in English
-Full text articles
Table V: Inclusion and exclusion criteria for studies.
Database Inclusion Criteria Exclusion Criteria
− Studies involving patients − Studies on paediatric patients
Scopus and/or − Studies on cognitively impaired patients
nurses who interact in a − Studies on language barrier due to
Cinahl language other than their native disability
language
Pubmed − Studies involving foreign
patients of
any nationality
− Studies involving adult patients
Results
The articles search carried out within the Pubmed, Scopus and Cinahl databases through
keywords organised in search strings, allowed the identification of 417 articles: 130 results
for the first and second question and 287 results for the third question. The total articles
selected and considered pertinent were, at the end of the analysis, 19 as follows divided: 6
for the first question, 6 for the second question and 8 for the third question. The flow - chart
below briefly represents the article selection process. The 19 selected studies include: 13
qualitative studies, 3 quantitative studies and 3 mixed method studies.
For each article, information was summarised about the title, author, publication date, type of
study, journal in which it was published, objective, sample, materials and methods, results
obtained, limitations of the study and conclusions (Appendix 1).
Results 417:
● 103 Scopus
● 261 Pubmed
● 53 Cinahl
Excluded after title screening
and removal of duplicates 367:
76 Scopus
245 Pubmed
46 Cinahl
50 articles selected for
abstract screening
Excluded after abstract
screening 23:
15 Scopus
5 Cinahl
Discussion 3 Pubmed
First27 articles selected
Research questionfor full
text review
What are the consequences of language barriers for foreign patients receiving care?
Excluded after full text review
for not meeting
From the literature it has emerged that patients experience different the
consequences due to
inclusion criteria 8:
the presence of a language barrier within the care relationship. These consequences have
been divided into the following three themes. 6 Scopus
2 Cinahl
19 articles/studies selected
for analysis
Miscommunication and Misunderstanding
The negative consequences of misunderstanding in communication between patients and
healthcare professionals cannot be underestimated. It may lead to adverse health effect for
patients (Karliner et al.,2007; Flores, 2005; Bischoff, 2012).
One study found that if an interpreter with medical training was not available promptly,
surgeons were more likely to use "generic" interpreters or their own language skills, often
without having full mastery of them, thus putting patients in the condition of consenting to
surgical procedures without fully understanding their usefulness and possible risks (Darshan
N. Patel et al., 2017). This goes against the principles of informed consent set out by the
Department of Health (Department of Health, 2009).
In another study, poor communication contributed to poor patient assessment, misdiagnosis
and/or delayed treatment, incomplete understanding of the patient’s condition and treatment
prescribed, and reduced trust in the services received (Moissac and Bowen, 2019). This
study also highlights a case of a patient who went to the doctor because of unpleasant
odours coming from her private parts, but because she had trouble expressing herself in a
language other than her own, the doctor diagnosed her with an infection. When she died
shortly after, it was discovered that she had uterine cancer.
Disparity in the quality of health care
Whether it is discrimination or miscommunication or any other negative consequence that
the patient experiences due to a language barrier, these create disparities in health
outcomes, such as a patient who does not understand the prescribed treatment and does
not follow it as he or she should. Some of the participants in the study by Moissac et al.,
perceived inequity and disparity in the quality of care they received (Moissac and Bowen,
2019). Similary, a number of studies have demonstrated that patients who experience
language challenges have worse health outcomes than those who speak the local tongue
(Divi et al., 2007; Squires, 2017).
According to Krampe et al., linguistic barriers have a detrimental effect on the quality of
treatments, patient safety, resulting in preventable complications and longer hospital stays
(Krampe et al., 2022). Analogous results also emerged from the Robertson et al. study
(Robertson & Salehi, 2016).
Dressler et al. noted that the style and manner used by interpreters influence the
effectiveness of communication during complex conversations about prognosis, care goals,
and end-of-life issues. For example, the discomfort experienced by the interpreter when
discussing topics such as serious illness or end-of-life care is reflected in their body
language and, in turn, affects how the patient receives the care that the nurse or healthcare
provider intends to deliver. This demonstrates the need for a higher level of language
interpretation than what is typically available (Dressler et al., 2021).
Second research question
What are the consequences of language barriers for nurses providing care to foreign patients?
Three themes emerged from the various articles examined.
Feeling of ineffectiveness at work
Nurses experienced a higher degree of unpredictability in their relationships with patients
belonging to ethnic minorities, given their lack of knowledge of what was considered
"normal" according to the culture of those patients. The fear of misunderstandings and
misinterpretations often led nurses to intentionally modify their behaviour when caring for
patients belonging to minorities (Debesay et al., 2014).
Evgin et al. also stated that the language barrier led to a perception of insufficient care
provided by nurses who, unable to communicate with patients, were unable to understand
whether they were providing culturally acceptable care or not. The majority of the nursing
students who participated in the study stated that they felt incompetent and inadequate in
providing psychological support and that they felt helpless in providing care to refugee
patients (Evgin, 2021).
