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Abstract
Objectives To identify language-related communication barriers that expatriate (non-Arabic) healthcare practitioners in the UAE encounter in their daily practice.
Design Qualitative study utilising semi-structured in-depth interviews. The interviews were conducted in English language.
Setting Different healthcare facilities across the UAE. These facilities were accessed for data collection over a period of 3 months from January 2023 to March 2023.
Participants 14 purposively selected healthcare practitioners.
Intervention No specific intervention was implemented; this study primarily aimed at gaining insights through interviews.
Primary and secondary outcomes To understand the implications of language barriers on service quality, patient safety, and healthcare providers’ well-being.
Results Three main themes emerged from our analysis of participants’ narratives: Feeling left alone, Trying to come closer to their patients and Feeling guilty, scared and dissatisfied.
Conclusions Based on the perspectives and experiences of participating healthcare professionals, language barriers have notably influenced the delivery of healthcare services, patient safety and the well-being of both patients and practitioners in the UAE. There is a pressing need, as highlighted by these professionals, for the inclusion of professional interpreters and the provision of training to healthcare providers to enhance effective collaboration with these interpreters.
- health equity
- health services accessibility
- health services administration & management
- international health services
- quality in health care
- risk management
Data availability statement
Data are available upon reasonable request. Anonymised interviews transcripts can be made available upon reasonable request made to the corresponding author.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- health equity
- health services accessibility
- health services administration & management
- international health services
- quality in health care
- risk management
STRENGTHS AND LIMITATIONS OF THIS STUDY’
The study employed a qualitative phenomenological design and purposive sampling, effectively capturing diverse healthcare practitioners' experiences with language barriers.
Comprehensive data was collected via in-depth interviews, with Van Manen’s method ensuring detailed and structured analysis.
The research team’s mixed academic and clinical background further enriched study interpretations.
Participants might have under-reported challenges due to career implications and potential restraint from recording during interviews.
Introduction and background
Communication is a vital component of human interaction and daily life activities. Clear communication is also critical for healthcare systems because the delivery of effective, high-quality and safe healthcare services depends on accurate communication. A 2015 report from the Harvard Medical Institution Risk Management Foundation investigated communication failures in healthcare and noted that in the USA, patient harm was directly connected to communication in 7149 cases.1 In addition, the report found that 44% of these communication failures caused severe harm (including death), 44% caused moderate severity harm and 12% caused low severity harm; these cases resulted financial losses for the healthcare system of about US$1.7 billion.
The UAE, a Middle Eastern nation comprising seven emirates and home to around 10 million people, is thriving both economically and politically. It stands out as one of the wealthiest, most peaceful and stable countries in the region. Its remarkable economic success and rapid development in various sectors have made it a magnet for expatriates seeking employment and settlement opportunities. The healthcare system of the UAE is particularly advanced, drawing healthcare professionals from across the globe. Remarkably, expatriates constitute about 97% of the healthcare workforce, underscoring the linguistic and cultural diversity within this sector.
The UAE and many surrounding Arabic countries have healthcare systems in which the majority of staff are overseas practitioners; therefore, language barriers can pose major challenges. For example, the medical and nursing workforce in the UAE is diverse and practitioners have differing cultural, linguistic, religious, socioeconomic, clinical and educational backgrounds. Southeast Asia (ie, the Philippines) and South Asia (ie, India) are the countries of origin for most medical and nursing staff, with other common source countries including Australasia, Europe and North America.2–4 These healthcare practitioners speak various languages and dialects, whereas the official language of the UAE and only language spoken by the majority of the local population is Arabic. Because of these language discrepancies, English is the language used in the healthcare system.
In addition to this diversity among healthcare practitioners, the UAE population (around 10 million people) is diverse. UAE nationals comprise around 11.4% (ie, 1.16 million people) of the total population, with other population groups being Indian (27.49%), Pakistani (12.69%), Bangladeshi (7.40%), Filipino (5.56%), Iranian (4.76%), Egyptian (4.23%), Nepali (3.17%), Sri Lankan (3.17%), Chinese (2.11%) and other (17.94%).5 A significant proportion of this population, especially UAE nationals and the Arab population, are not competent or literate in English, despite this being the main language used in the healthcare system. Using the English language mainly for communication in the healthcare system has created gaps between healthcare practitioners and patients. In addition to practitioner–patient communication issues, which affect the quality and safety of services, the diversity in the UAE healthcare system has contributed to other professional and educational problems; in exceptional situations (eg, the recent pandemic), this threatened the stability and sustainability of healthcare services.2 6 Overall, this diversity has affected the provision of comprehensive and culturally competent healthcare for patients from different cultures, religions and ethnicities.7
The literature shows that there is more to communication than merely speaking the same language. A previous study noted that language barriers have cultural connotations8 as language and culture work in parallel. Therefore, both language and culture need to be considered when discussing communication. It is sometimes believed that healthcare providers can ‘learn as they work’ with patients from other cultures. Although elements of this assumption may be relatively true, there are dangers associated with this simplistic attitude in the healthcare context, as it may result in misunderstandings or mistakes (eg, misdiagnosis, violation of patients’ beliefs) that have associated financial and other costs.9 Culture-based challenges identified in Arabic and Muslim contexts include managing non-verbal communication issues. For example, although many cultures use touch as part of communication (eg, shaking hands), this contact may not be appropriate in these contexts, especially between men and women. These limitations in the use of non-verbal communication techniques may pose further challenges for some healthcare practitioners, such as nurses, whose roles include frequent patient encounters.7 10 11
Delivering high-quality healthcare services in a diverse context requires multi-faceted cooperation. Research suggests that poor patient outcomes and compliance along with increased health disparities may result from a lack of culturally competent care, irrespective of available services12 13 ,14. A pertinent example can be found in a recent study by Al-Yateem et al (2023).15 The research highlighted that communication barriers and past negative experiences with healthcare professionals led some Emirati parents to prefer using traditional and herbal remedies for their children before seeking professional healthcare. This preference, stemming from factors such as feeling rushed, misdiagnoses or not being listened to, culminated in delays in treatments and occasionally in untreatable complications. Such challenges faced within the UAE healthcare system reinforce the reliance of many parents on home remedies. This underscores the significance of addressing communication barriers and ensuring culturally competent care in the healthcare system to enhance the quality of services and user experiences.
Previous studies indicated that medical providers with poor cross-cultural communication skills had more job-related anxiety and dissatisfaction than those that had these skills.16,9 It has also been reported that health professionals tended to rely on bilingual colleagues or patients’ relatives as interpreters to cope with language-related communication barriers.17 18 However, given that the use of these casual interpreters has previously been associated with several issues (eg, miscommunication, poor quality care, confidentiality problems), it may not offer a practical solution.19 A more common practice in addressing language barriers in healthcare settings is to utilise professional interpreter services. These trained individuals bridge the language gap and also understand the nuances, cultural contexts and medical terminologies, which ensure a more accurate and efficient communication.20 21 Not incorporating such services where needed can potentially compromise patient care and safety. Furthermore, another study argued that discrepancies in communication related to language may increase patients’ psychological stress and result in errors with medically significant consequences, whereas patients in language-congruent encounters do not have this exposure.22
In addition to unfamiliarity with the language and culture23 highlighted a number of other factors that contributed to poor intercultural communication in the healthcare context, including patients being too unwell or anxious to focus on communicating clearly, providers being technology-focused and time limitations. It is important to note that language-related communication problems impact both healthcare practitioners and patients. Associated problems include miscommunication around details of diagnoses, care/other instructions and treatment options, which may reduce patients’ adherence and increase their anxiety.17 The access of patients to high-quality and timely healthcare service may be negatively affected,8 which influences their trust and satisfaction from the services they receive.
Language-related communication problems between healthcare professionals who does not speak Arabic and their local patients are common in the UAE. Therefore, we investigated language barriers encountered by healthcare practitioners when communicating with patients/patients’ families in the absence of a shared language in different healthcare contexts in the UAE. We explored practitioners’ perceptions of the impact these language barriers had on their daily practice as well as their suggestions regarding potential solutions.
Methods
Study design
This study used a qualitative exploratory phenomenological design. This design was considered appropriate to answer our research questions about healthcare practitioners’ experiences in relation to language-based communication challenges and barriers encountered during daily practice in healthcare settings in the UAE.
Study participants and setting
Participants in this study were expatriate healthcare practitioners working in the UAE who were not fluent in Arabic. The determination of their fluency in Arabic was based on their self-assessment rather than a formal language proficiency test. We included participants with various medical and nursing specialties from different UAE healthcare institutions. Study participants were diverse in terms of their years of work experience, had experience working in different healthcare systems and settings, and spoke different languages than their patients.
We purposively selected a sample of volunteer participants with diverse specialties from major hospitals in different Emirates. This allowed us to capture differing perspectives and insights from practitioners with varying levels and types of work experience. After gaining approval from the relevant hospitals, an email was sent to healthcare staff in each hospital that included information about this study and an invitation to participate. The invitation emphasised the confidentiality of their participation and the protection of their data. Interested participants responded to the email invitation, and arrangements were made for their interviews.
Data collection
Data were collected through in-depth semi-structured interviews. The interviews were conducted in English language.
An interview guide was developed to guide the interviews and maximise the data collected (online supplemental file). The interview guide covered participants’ native language, other languages they spoke, field of specialisation, years of experience in their respective practice areas, overall professional experience (including experience in their home country and other countries in which they had practiced) and the duration of professional experience in the UAE. These initial questions were followed by a general discussion about the difficulties and challenges faced when communicating with patients or patients’ relatives with whom they did not share a common language (eg, English, the participant’s native language or any other language). Probing questions were used to elicit details about the consequences and effects of these challenges, coping strategies used and effective approaches to address these challenges. In addition, participants were asked about any support available to help them tackle this issue and recommendations for future strategies that could be helpful.
Supplemental material
Each interview lasted approximately 30–45 min and was conducted at a location agreed on with the participants to ensure their comfort and maximise the information obtained. The interviews were recorded and then transcribed for analysis. The recording method minimised the impact on the quality of data obtained. To protect participants’ privacy, all data, including participants’ interview recordings, were anonymised and kept confidential, and no details that could potentially reveal their identity or workplace were reported. These considerations were crucial for improving the quality of data obtained given the sensitive nature of the topic, as participants shared experiences and difficulties they had encountered while caring for patients and families. This study included 14 healthcare practitioners. Data saturation was achieved with this sample. The data was collected over a period of 3 months from January 2023 to March 2023.
Data analysis
The data collected in the in-depth interviews were analysed using Van Manen’s selective or highlighting approach, following the iterative process followed in the hermeneutic circle. The process started with verbatim transcriptions of the audio recordings, which allowed us to grasp participants’ descriptions of their experiences in their entirety. Each transcript was read multiple times not only to foster familiarity with individual participant narratives (the ‘parts’) but also to gain an overall understanding of the collective experiences (the ‘whole’). Initial notes were recorded during these readings.
Drawing on the principles of the hermeneutic circle, our understanding of individual statements was enriched by our evolving comprehension of the overall narrative, and vice versa. Throughout this process, we identified statements or phrases that seemed ‘particularly essential or revealing’ about the participant’s experiences.24 These key statements, phrases or words were highlighted for deeper examination.
Subsequent to this, initial descriptive coding was undertaken. The highlighted portions were coded using participants’ own language, grounding our analysis in their lived experiences. Codes with similar content were grouped iteratively and then were merged together and organised into overarching themes.
One issue that is worth noting is the composition of the research team; all research team members are fluent in both Arabic and English. While some are native English speakers with fluency in Arabic, others are native Arabic speakers proficient in English. This linguistic diversity enables the team to discern subtle meanings and emotions in the data. Such diversity ensures a comprehensive and varied interpretation of the data. The team consistently discussed their findings to cover all data facets and minimise any unintentional cultural or linguistic biases.
Research team
The study team comprised male and female researchers with postgraduate qualifications. The team currently worked in academic institutions but had previously held clinical roles. All interviews were conducted by a female research assistant who was master’s-prepared and familiar with the interviewing process. The team had no relationships with the participants either before or at the time of the interview. However, to facilitate information sharing during the interviews, the interviewer took the time to establish a relationship with participants and started each interview with general questions to break the ice and strengthen the relationship before moving to the specific interview questions.
Ethical considerations
Healthcare practitioners who agreed to participate in this study received an information sheet that outlined their rights, including the right to withdraw from this study at any time without giving a reason. Furthermore, participants were assured that their participation was anonymous and that the information provided would be kept confidential and only used for this study. Participants were asked to sign a written consent before conducting the interview.
Patient and public involvement
None.
Findings
The interviewed participants consisted of a diverse group of medical and nursing practitioners from various countries, including India, Pakistan and America. They represented both the public and the private healthcare sectors in the UAE. Approximately two-thirds of the participants were from the public sector, with the remainder from the private sector. Their specialties included ophthalmology, intensive care, anaesthesia, nephrology, critical care medicine, obstetrics and gynaecology, paediatrics, urology and internal medicine. Figure 1 provides a detailed breakdown of the participants’ characteristics.
Participants’ characteristics. aYears of experience refers to experience in the UAE.
The participants’ experience in the UAE varied, ranging from less than a year to over two decades of practice. For added context, while the public sector in the UAE dominates health services coverage, the private sector also plays a significant role in service provision.
Regarding Arabic language proficiency, participants self-assessed and described their capabilities. While most of the participants reported a basic understanding of some Arabic words and phrases, only one self-described having an intermediate level of proficiency.
The analysis of the interview transcripts revealed three main themes: Feeling left alone; Trying to come closer to their patients and Feeling guilty, scared, and dissatisfied.
Feeling left alone
All participants noted that in their workplace, non-Arabic-speaking medical practitioners were not offered formal professional development to address language-related communication challenges in their clinical work. Some participants reported that they had faced similar challenges in their previous work in other Gulf Cooperation Council countries.
There has never been formal training in the Arabic language received. (P5)
No formal training in Arabic language received in all the Gulf countries I worked in, including [the] UAE. (P14)
Participants also reported their workplaces did not have facilities for formal interpretation services, meaning no professional medical interpreters were employed on either a permanent or a temporary basis to facilitate communication with patients. Many participants indicated they tended to ask medical and other staff working with them to do translation for them when necessary. They described how this meant that they were often left alone to cope during difficult situations.
I'll tell you from my experience in Bahrain, Saudi, and Dubai. The only place where it was formally available was in Saudi in government hospitals; we have a woman who sits there for translation. If three or more doctors need her, then it becomes more difficult. But here in hospitals, I rely on the nursing girls who speak Arabic and have a little time to come from their work or duty. And if they are busy, we cannot ask them to come. So, we use anybody from the nursing girls to the receptionists. (P7)
Some participants indicated that they attempted to address the language barrier in their clinical work by relying on a mix of broken Arabic and English, along with non-verbal language techniques. This meant that they could perform their clinical duties without requesting translation assistance from colleagues. However, they noted that this approach was not always easy and could cause problems if an incorrect word or phrase was used in a certain context or a word was not pronounced properly. At times, this could lead to even bigger issues. This was further complicated by the many different Arabic dialects; some words that participants used could be easily understood by some Arabic patients but not by others who used a different dialect.
Many times, I try to communicate with broken Arabic; I do communicate. But it does not work sometimes. I will end up in a bigger issue, saying the word again and again until they understand it. This is frustrating for me and for them. (P12)
Now, Emirati Arabic is what I am mostly used to. Egyptian Arabic is sometimes difficult to understand because the terms they use are slightly different from what the Emirati use, and there are many other dialects. (P9)
Those who are coming from Jordan, Syria, Iraq, their dialect is slightly different from what Emirati speak. (P9)
However, at times the use of broken Arabic was considered helpful, especially when words/phrases were correct. Participants noted that many patients and their families appeared to be more comfortable with this form of communication and were receptive of the messages.
Many of them will be surprised when I say it in Arabic words; they will like it and laugh, and they look more engaged, even with the simple words that I use. (P13)
Participants highlighted various differences between the UAE and their home countries in terms of aspects of the healthcare system (eg, increased use of computers during patient encounters, which reduced actual time spent interacting with patients). These differences could sometimes increase the difficulty of their work as they sought to focus on patient treatment. Many participants highlighted that language barriers presented the most significant challenge in their workplace and negatively impacted their communication with Arabic-speaking patients and the families. Participating healthcare professionals suggested that speaking directly to their patients (ie, in Arabic) was an important consideration. They noted that this would facilitate and enhance communication with their Arab patients.
Sometimes, we feel the language barriers come. Because we can communicate with the patients more if we know Arabic, but due to this, we feel more restricted. (P2)
From my experience, there are three challenges; one of them is the language, of course. (P4)
Participants reported that the communication problem worsened when none of the patient’s family members present understood English. If at least one family member could speak or understand English, healthcare practitioner–patient communication was facilitated. This language barrier often meant that participants felt unsatisfied with their performance because they were concerned about not being able to convey complete messages and proper treatment or care directions to their patients.
I find it difficult to communicate with them. And this is where I worry. The challenges I would say I am not very sure if I conveyed the message or not. (P7)
Some participants mentioned they had encountered serious life-or-death matters that they felt could not be ignored. In these situations, optimal communication was required to avoid threats to life.
…there are two scenarios, what I will say: 1) If the patient has an ectopic pregnancy or 2) the patient has a small baby because they are two life-threatening things. One for the baby and one for the mother. I have to make sure that the patients fully understand the situation. Sometimes the idea that they did not understand me scares me. (P7)
It was noted that such risky situations had potential to negatively impact healthcare practitioners, especially if a patients left the encounter without a sufficient understanding of the explanations and instructions they were given. Some participants also noted that they preferred to speak directly to their patients without a third party present to provide translation, but this was not possible without being fluent in Arabic.
I want to ensure that they understand my message. They go with a little more than half a message. It makes me feel a bit scared of how to communicate in such a scenario. I have used nurses also, or nursing assistants. But again, I feel I can do better if I can speak directly to them. (P7)
Feeling insufficient: Trying to come closer
Participants believed that healthcare practitioners working in the UAE should at least try to acquire basic terms in the local Arabic language to better communicate with their only Arabic-speaking patients. Some participants noted that patients often demanded detailed information in Arabic, which could cause additional stress and challenges. This was noted as a major issue during a patient’s first visit to the clinic when communication was particularly challenging as healthcare professionals lacked sufficient information about their health status.
Patients are looking for details; they have lots of questions. If the patient is diagnosed with diabetes and if I have to treat them by giving them injections in the eye or I have to give them laser…there is a lot of information that needs to be given to patients. (P1)
Some participants noted that communication in a patient’s native language was required to help them stay calm and offer counselling.
It is difficult with patients who are very anxious about it, and if I have to calm them down or counsel them, then it gets very difficult. (P1)
Another challenge related to insufficient language skills was communicating with patients about critical health issues (eg, kidney failure), where detailed information needed to be exchanged.
I know that sometimes patients are very sensitive. In our field, with kidney failure cases, it is very difficult, like breaking bad news. I say to my patient you require daily dialysis; I use very superficial broken Arabic terms for that. (P3)
Furthermore, participants suggested that healthcare practitioners needed to appreciate the importance of learning the local language, especially when this allows to provide a better quality and safer care for their patients.
Language is very important, especially for us Indians. We know the value of a language, as India has lots of languages. If I know one language I can speak, then I can speak to 1–100 million people who speak this particular language. (P3)
In addition, participants highlighted that learning at least some of their patients’ native language always made a difference when attempting to establish relationships with patients.
So, to know something is better than to know nothing…the language is very important, especially with locals. It makes a difference if you know how to speak some languages…You will build trust and satisfaction, especially since we are dealing with human beings. (P3)
An important point raised by participants was that the language barrier and associated communication problems had a serious impact on them as healthcare practitioners. It was noted that this issue could result in lost confidence in performing their job.
Initially, it was…a’ah…Communication was very difficult because I don’t know any Arabic and here, they speak mainly Arabic. So, it was really a problem, and I was frightened to go to the office. And I don’t know what I will face sometimes if I am called. I don’t know what they will give me. (P11)
Many participants offered examples of situations that highlighted the importance of proper communication with patients in clinical environment, especially as they often needed to exchange complex information about patients’ medical history, diagnosis and care. Several participants shared details of challenges they had experienced because of the lack of professional interpreters in their workplace. Participants also noted that in some cases, it was preferable for the interpreter to be a doctor to ensure important information was properly conveyed.
We need interpreters for the families who do not know any English. Even if they know some English, I prefer to use interpreters because there is some technical stuff to be translated. It’s better to have interpreters, which I prefer to be medical doctors, as they know all the medical terms; even nurses and healthcare staff will not be able to express certain medical issues. (P6)
Patient–clinician communication in the first encounter was noted to be more complicated than communication in subsequent visits or with patients who had visited the clinic frequently and could understand (at least partially) some terms and instructions used. Patients’ attitudes were noted as sometimes making communication more difficult, as uncooperative patients were considered more challenging to communicate with.
Patients are looking for details, and they have lots of questions. Added to that, communication gets difficult if the patient is not cooperative with the doctor and has lots of stress and fears. As a result, the doctor requires a good bank of terms and phrases in Arabic to enable him/her to handle such difficult situations. (P1)
Participants indicated that cultural differences could also complicate communication, as healthcare practitioners needed to be familiar with the culture as well as knowing the local language. Becoming familiar with and accepting other cultures was considered an important additional task that must be undertaken.
Settling down is important for medical practitioners who come to work in another country to show better professional performance. In addition to language issues, there is the culture. Language and culture often go hand in hand in many scenarios and situations. They seem to be complementary. (P6)
Feeling guilty, scared, and dissatisfied
Participants reported that struggling to communicate effectively and accurately share important information with Arab patients often left them feeling frustrated and dissatisfied.
So bad we feel sometimes. Otherwise, we do not face any professional issues with this. But for our satisfaction, we feel it is good to speak the patient’s language. (P2)
In addition, participants’ narratives suggested that worry about not being able to accurately communicate essential information regarding patients’ health conditions and treatment could have various negative impacts, both at the psychological and professional domains.
The challenge, I would say, is that I am not very sure if I conveyed the message or not. (P7)
It was also highlighted that participants encountered cases that concerned serious matters that could not be ignored. These cases required urgent and timely solutions, especially given the potential for negative consequences for both patients and healthcare practitioners if a patient left the clinic without clearly understanding important messages related to their health condition and treatment.
These are some of the potential risks that could occur as a result of the language communication barrier, and that is a scary matter! I want to ensure that they understand my message. They go with a little more than half a message. It makes me feel scared about how to communicate with such a scenario; I have used nurses also, but nurses or nursing assistants. But again, I feel I can do better if I can speak directly to them. (P8)
Participants sought to treat their patients as whole individuals and address both physical and emotional needs. However, when language-based communication barriers existed, important information for patients may not be conveyed accurately.
Not just you do want to be in trouble. It’s not just a doctor trying to save a patient’s life. You want to express the importance, but not being able to…The message is not conveyed. (P10)
Participants stated that being unable to ensure that important healthcare messages were properly communicated to and understood by their patients gave rise to concerns and fears about potential negative consequences (psychological and professional).
Yeah, and you worry that this patient is not listening, and they could come back with a bigger problem. (P14)
Several participants gave examples of the impact of language barriers on effective communication based on their past experiences in similar countries and contexts. Understanding the local language would help them to communicate more effectively with patients but would also offer some protection from potential risks.
Like when I first came to Saudi Arabia, I went to Jeddah first, then from Jeddah to Dammam. Then, there was my passport stamping. I actually came to Saudi during Ramadan; it was the first day of Ramadan and I was not able to receive my passport from the first day I arrived. Somebody told me: go, go, go, and others said: come, come, come. Something like: He did not know English and I didn’t know Arabic. He wanted to take me to the Airport in Dammam, a particular airport, but he couldn’t understand me, and I didn’t understand him. And he went to the computer and I said, why? He said something, he wanted to deport me. Yes, scary, sometimes misunderstanding communication becomes very difficult. (P12)
Participants expressed that reliance on help with patient communication from Arabic-speaking counterparts introduced a risk for various communication errors, potentially leading to patients missing important healthcare messages and instructions. As a consequence, negative outcomes may arise that adversely impact both parties. Healthcare practitioners may be blamed for not the consequences of language-related communication problems, such as provision of insufficient details about diagnoses and treatment and medical decisions based on incomplete information. In some cases, such issues could have legal ramifications.
…Yes, we rely a lot on interpreters from co-workers, etc., but is that correct? Is it appropriate? Is the message being conveyed properly? Is it what we want to say? We don’t know, we are not sure. What if it was not accurate? What if they told me something not correct? I will make a wrong decision based on that. I don’t know. (P5)
Discussion
This study investigated challenges associated with language barriers for healthcare practitioners working in diverse healthcare contexts in the UAE. All participants had experienced language barriers in their encounters with patients or patients’ family members, as they spoke no Arabic or only knew some Arabic words/phrases. Our findings suggested that language barriers negatively impacted healthcare practitioners’ daily clinical practice. Participants reported sometimes feeling guilty, scared and dissatisfied because of their inability to convey medical information accurately because of the language barrier. Social identity theory (SIT) suggests that healthcare practitioners derive a sense of identity and self-esteem from their professional group with a shared language and culture. When they cannot effectively communicate with patients or their families because of language barriers, they may feel inadequate and experience dissonance in their professional identity.25
These negative impacts on healthcare practitioners’ self-concept and self-esteem can have severe consequences, including life-threatening misunderstandings, adverse psychological effects and various professional impacts. Therefore, comprehensive efforts are required to improve health equity by addressing language barriers.26 Participants in this study recommended using professional medical interpreters to overcome language barriers in the healthcare context. However, it is essential to note that effective collaboration with interpreters is a skill that needs to be learnt and developed by healthcare practitioners.27 This highlights the importance of having access to interpreters and understanding how to effectively work with them to ensure accurate communication and understanding between healthcare practitioners and patients who do not speak a shared language.18 28 A previous study found that using professional interpreters who were present at the location was a frequently suggested solution for overcoming language barriers in healthcare settings.27–29 However, the use of professional interpreters may vary by the type of healthcare professional and clinical situation.27 29
Participants occasionally relied on patients’ family members or bilingual staff as interpreters, even though they may lack proficiency in medical terminology, potentially side-lining professional interpreters.29 30 Using ad hoc interpreters may be detrimental to effective healthcare practitioner–patient communication and should not be considered a replacement for professional interpreters in healthcare settings. Another critical aspect brought to the fore is the occasional dependence on patients’ family members, including children, to serve as interpreters. This approach, while seemingly convenient, poses a risk of compromising the patient’s confidentiality and inhibiting the open discussion of sensitive or private matters. Relying on ad hoc or family members interpreters, especially those without proficiency in medical terminology, can lead to inaccuracies in translation and potential miscommunications. Moreover, patients might withhold critical information or fail to ask important questions due to discomfort or fear of judgement from their family members. Thus, while family involvement can be beneficial in various aspects of patient care, serving as interpreters may not be the optimal role for them, particularly when discussing sensitive topics. Comprehensive professional interpretation services, familiar with both medical terminology and the nuances of patient privacy, remain paramount.
The UAE government recognises the significance of overcoming language barriers in healthcare. Existing guidelines advocate for the use of professional interpreters, emphasising their importance in ensuring accurate and efficient communication. However, gaps persist, around coverage and availability, also in relation to training healthcare practitioners in maximising the benefits of working with interpreters. Observing health systems from countries with significant immigrant or minority populations, such as Canada or Australia, reveals a more structured approach to integrating interpreters into the healthcare process, ensuring inclusivity and understanding.
Participants in this study believed that healthcare professionals should be proactive in learning basic medical terms in Arabic to ensure they could communicate with their patients in their native language. In the global healthcare landscape, cultural sensitivity is paramount, particularly given the mosaic of nationalities present in settings like the UAE. Specifically focusing on the Arab population, which serves as a case exemplar, it is clear that linguistic competence goes together with cultural understanding. Arabic-speaking patients might not only come with linguistic preferences but also unique cultural beliefs regarding healthcare, family dynamics and doctor–patient relationships. Addressing language barriers without accounting for these cultural nuances may only partly bridge the communication gap. This aligns with the self-categorisation process described in SIT, whereby individuals categorise themselves into a group and align their behaviour with the norms and expectations of that group.31 Learning basic medical terms in the local language allows healthcare practitioners to demonstrate their affiliation with the cultural group of their patients, which can increase patient trust and satisfaction. This was consistent with a study that showed providing care in a patient’s primary language improved communication, built trust and enhanced the quality of care.32 Therefore, learning basic medical terms in patients’ native language offers an innovative and effective solution to address the language barrier issue and improve healthcare services for Arab patients.
Our participants indicated that the ability to communicate with patients in their local language was necessary to help patients become calm and provide counselling. Effective communication in a patient’s preferred language improved patient satisfaction and perceptions of care quality. Effective communication is also crucial for building trust and establishing a positive relationship between healthcare providers and patients.8 10–13 Participants highlighted the need for healthcare practitioners to be familiar with their Arab patients’ culture. This was consistent with previous studies that emphasised the need for healthcare providers to be culturally competent.10 11 15 25 31 33
Concerns associated with being unable to accurately convey medical messages to patients may negatively impact healthcare practitioners psychologically and professionally. This fear is consistent with a social identity threat, whereby individuals perceive that their social identity is threatened when they face situations that compromise their ability to perform effectively.25 31 Previous studies also reported that language barriers had a negative impact on psychological well-being and job satisfaction among healthcare providers.34 In particular, poor communication can affect the delivery of quality care, potentially leading to poor patient outcomes, lost resources and increased costs to the healthcare facility.1 Failures in communication may also negatively affect patient and staff satisfaction.35 Cultural differences mean that language-related communication barriers may be compounded by some aspects of communication (eg, use of abrupt language, too much or too little eye contact, rushed explanations), which negatively influence patients’ experiences. Therefore, providing specific communication training for healthcare practitioners may contribute to improved patient outcomes and satisfaction.
Language barriers can have major impacts on healthcare delivery, patient safety and satisfaction. Comprehensive efforts are required to improve health equity by addressing these challenges, including using professional interpreters, educating staff on effective communication and familiarising themselves with patients’ cultural differences. Addressing language barriers is crucial for providing quality healthcare services, building trust and rapport with patients, and improving patient outcomes.
Conclusions and recommendations
This research underscores the profound influence of language barriers on healthcare in the UAE, impacting patient safety, the quality of care and the well-being of healthcare practitioners. Comprehensive strategies are essential for advancing health equity in light of the identified challenges.
The integration of professional interpreters into healthcare settings stands out as a critical solution to bridge the language gap. Moreover, it is vital for healthcare professionals to be equipped with the skills necessary to collaborate effectively with these interpreters. Another vital aspect is the encouragement for healthcare practitioners to learn basic medical terminology in Arabic, which can foster improved communication with Arab patients and enhance the overall care experience. Beyond language, gaining an understanding of the Arab culture is imperative for healthcare practitioners. This cultural familiarity can amplify the depth and effectiveness of patient interactions, ensuring that care is both comprehensive and sensitive to patients’ backgrounds.
The implications of this study extend to various stakeholders. Policymakers can utilise our findings to craft more informed healthcare policies, ensuring effective communication in diverse settings. Corporate entities might consider introducing specialised training modules to equip their staff with the necessary linguistic and cultural skills. On the hospital administration front, there is an urgency to ensure that professional interpreters are accessible, fostering seamless communication between patients and practitioners.
Future research directions could encompass exploring the perspectives of Arabic-speaking patients. Such an endeavour would provide deeper insights into the challenges of linguistic communication in the healthcare context. In conclusion, addressing the interplay of linguistic and cultural nuances is crucial in healthcare. Such considerations are pivotal for enhancing the quality of care, building trust and ensuring optimal patient outcomes.
Study limitations
This study has several limitations that should be considered when interpreting the findings. First, the study relied on participants’ self-assessment of their Arabic language proficiency rather than conducting a formal language proficiency test. Self-assessment can be prone to biases, with individuals potentially underestimating or overestimating their abilities.
Additionally, participants were asked to share their experiences and difficulties encountered during their professional practices. Given that admitting linguistic or professional shortcomings might be perceived as having implications on their career, there could be a hesitancy among some participants to fully disclose or elaborate on certain challenges. This could lead to potential under-reporting or selective sharing of experiences.
The study’s recruitment strategy, which purposively selected participants from major hospitals in different Emirates to gain diverse insights, might have inadvertently excluded experiences of healthcare practitioners from smaller or rural healthcare settings. This could potentially limit the generalisability of the findings.
Another point to consider is the potential influence of the interview recording. While steps were taken to ensure rapport-building and create comfortable environments for the participants, the presence of the recording device, even though intended to ensure data accuracy, might have made some participants more cautious or restrained in their responses.
Finally, while our study provides valuable insights into the perspectives and experiences of healthcare professionals, it is important to acknowledge the intrinsic nature of communication as a two-way process. The absence of patient perspectives in our research presents a significant limitation, as their insights could have further enriched our understanding of the communication challenges faced in healthcare settings. The missed opportunity to capture patient experiences may have potentially limited the comprehensiveness of our findings.
Data availability statement
Data are available upon reasonable request. Anonymised interviews transcripts can be made available upon reasonable request made to the corresponding author.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Institutional Review Board of the University of Sharjah (Ref # REC-21-04-08-01-S). Participants gave informed consent to participate in the study before taking part.
References
Supplementary materials
Supplementary Data
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Footnotes
Contributors NA-Y conceptualised and designed the study, supervised the research team, wrote the manuscript and provided critical revisions. HH conducted the primary experiments, analysed the initial data and contributed to writing the methods section. AS assisted in study design, managed data collection and contributed to the discussion section. RM conducted literature review, contributed to the manuscript’s background and provided technical support during experiments. IR assisted in data analysis, interpreted results and contributed to the results section of the manuscript. SAR managed participant recruitment, contributed to the methodology section and assisted in data interpretation. MS provided logistical support, managed resources and contributed to the manuscript’s supplementary materials. FRA assisted in drafting the manuscript, provided critical feedback and contributed to the final editing and proofreading. All authors read and approved the final manuscript. NAY is the guarantor of this work.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.