Sep 27, 2021, By: Michelle Leung
- Francophone patients living in areas where they are a linguistic minority have serious difficulties accessing health services in French. They may have no other choice than to use services in English. In such cases, many Francophones face language barriers that can threaten their safety.
- The use of bilingual relatives, interpreters, or translation technologies is not a substitute for the care that bilingual nurses can provide.
- Bilingual nurses who practise active offer fulfil their ethical obligation to provide accessible services and demonstrate cultural competence through giving their patients a choice. By being aware of language barriers and their impact on health, nurses can adjust the environment to ensure the delivery of culturally safe and effective health care to their patients.
Fifty to 55 per cent of francophones living in communities in which they are the linguistic minority never or rarely have access to health services in French. This finding was revealed in an analysis of 71 francophone communities outside Quebec across Canada, excluding the Northwest Territories (Comité consultatif des communautés francophones en situation minoritaire [CCCFSM], 2001).
According to another Canadian study, 20 per cent of francophones living in such areas do not seek health services when they are not available in French for fear of not understanding the services rendered, or being misunderstood by the care provider (de Moissac & Bowen, 2018).
The impact of language barriers on patient safety manifests itself when the limited availability of services in French forces francophones to depend on services in English. In this article, the author reflects on the negative effects of language barriers on the safety of francophone patients living in a unilingual English environment and discusses the opportunity that bilingual nurses represent in ensuring the safety of these patients.
Language agreement between the patient and the care provider is essential for effective communication; it facilitates patient assessment, examinations, pain management, informed consent (de Moissac & Bowen, 2018), and most importantly, patient-centred care.
As a result of poor access to services in the patient’s preferred language and the existence of language barriers with health-care providers, minority language populations in Canada have an increased risk of diagnostic errors, poorer health outcomes, lower adherence to treatment, and a lower rate of satisfaction with care and services (Bowen, 2015).
One of the most dangerous misconceptions is that if a patient speaks a little English, they do not need an interpreter or provider who speaks their native language (Bowen, 2015). However, this situation increases the risk because there is an illusion of proper communication. When the patient does not speak English at all, by contrast, the provider recognizes that there is a problem and takes extra precautions.
Nurses in Canada should therefore note the risk this myth poses for francophones who speak a little English. Nurses must also be aware that even francophones who can normally communicate in English may lose this ability during situations of stress or intense pain, or when they are under the influence of medication (de Moissac & Bowen, 2018).
The limits of using bilingual relatives, interpreters, and translation services
Faced with language barriers and the potential consequences mentioned above, health-care providers and facilities may resort to bilingual family members, interpreters, or online translation services to establish some form of communication. However, such solutions are associated with significant problems.
Relatives may omit information provided by the patient or health-care provider, or they may add information to what the patient or provider is saying; substitute words, concepts, or ideas; or use inaccurate words for anatomy, symptoms, or treatment, and other messages (Bowen, 2015).
Trained interpreters also have limitations: difficulty scheduling, lack of availability, patient confidentiality issues, and an overall reduction in the patient’s comfort level when interacting with the health-care system (Ali & Watson, 2017). Even when interpreters are available, communication through these intermediaries is not always successful, especially when a patient is stressed, in pain, or under the influence of medication or anesthesia. Ali & Watson (2017) suggest that in such situations, bilingual nurses who can speak the language of the patient can be especially useful.
The use of technologies, such as Google Translate, is another common attempt at overcoming language barriers. According to Patil and Davies (2014), however, Google Translate’s accuracy is only 57.7 per cent when used for medical purposes, and the authors conclude that it should not be relied on in such cases.
Additionally, in another study, French-speaking participants stated that the benefits of Google Translate are limited in emergencies or during mental health consultations, and that it is inadequate for meaningful medical encounters (de Moissac & Bowen, 2018).
Therefore, in my opinion, the use of relatives, trained interpreters, or online translation services is not an adequate substitute for the care provided by bilingual nurses. Unlike the majority of relatives, bilingual nurses know medical terminology. Unlike trained interpreters who are available only during certain hours, bilingual nurses are constantly at the bedside and can establish a meaningful relationship with their patients. And unlike Google Translate, bilingual nurses understand the context of the words used and are therefore more likely to provide accurate and relevant translations.
Thus, bilingual nurses occupy a privileged position: they are the voice of the patient to communicate with all those who do not speak their language. For each interpretation, bilingual nurses act as advocates for their patients to ensure their needs are heard.
Bilingual nurses are well placed to initiate bilingual communication (active offer)
Communication is central to the delivery of culturally safe care (Canadian Indigenous Nurses Association, 2009). Since language is necessary for effective communication, it is essential that nurses play a leading role in being the bridge between language, communication, and cultural safety. This can be accomplished by making an “active offer” of services in the patient’s preferred language:
Active offer means to offer, in a proactive way, and at first point of contact with the patient, services in the patient’s official language of choice. More specifically, it means that we enable patients to express themselves and to be served in the official language they feel most comfortable. In healthcare, the active offer not only allows patients to communicate more easily and to be understood, but it also helps healthcare professionals to provide quality services that are safe, ethical and fair, especially for linguistic-minority communities (Association des collèges et universités de la francophonie Canadienne, 2021).
In Canada, this means that health professionals offer their clients the choice to receive services in French from the start — the client or patient need not ask. Indeed, the patient may “feel intimidated if they have to demand respect for their language rights” (Savard, Casimiro, Benoît, & Bouchard, 2014, p 86, translation).
When providers make an active offer, they respect the patient’s language rights by respecting their language preference; cultural safety is thus reinforced. When bilingual nurses provide this active offer, they are demonstrating cultural competence.
It should also be noted that according to the CNA Code of Ethics for Registered Nurses, nurses must advocate for “accessible health-care services at the right time, in the right place, by the right provider” (CNA, 2017, p. 18). Thus, by initiating care in English and French, bilingual nurses are fulfilling their ethical obligation to provide accessible services to French-speaking patients.
On a personal note
As a recent graduate of the University of Alberta’s bachelor of science in nursing (bilingual), I look forward to using my multilingualism in patient care. I still remember the first time when, as a student, I offered bilingual care and services in the patient's language. It was during my first clinical internship in a long-term care centre.
Even francophones who can normally communicate in English may lose this ability during situations of stress or intense pain.
I approached a rather reserved resident with a warm “hello, bonjour,” and her face immediately lit up. She responded enthusiastically, “You can speak French?” We then began a long conversation in French about her family and travels. The instantaneous connection that was established when she realized I could help her in her language was incredible and demonstrates why the active offer of “hello” and “bonjour” is so important. I feel privileged to be able to provide this choice of language to my patients.
Finally, it is just as important that nurses be aware that the language barriers faced by francophones in minority communities, and the resulting consequences for their health, are similar to those with which immigrants who find themselves in a linguistic minority must also contend.
When my family and I arrived in Canada from China in 2007, I experienced first-hand the consequences of a language barrier when accessing health care and social services. From these experiences, I recognized the enormous importance that receiving services in one’s native language can have for the comfort of patients and for the quality of care, and for establishing therapeutic communication and trusting relationships with the health-care team.
Language and communication play a key role in the delivery of safe and effective health care, no matter where you are in the world. Such awareness enables nurses to recognize the risk faced by patients of linguistic minorities and to adapt the environment in order to offer them safe care and services.
Ali, P. A., & Watson, R. (2017). Language barriers and their impact on provision of care to patients with limited English proficiency: Nurses’ perspective. Journal of Clinical Nursing, 27(5–6), e1152–e1160. https://doi-org.login.ezproxy.library.ualberta.ca/10.1111/jocn.14204
Bowen, S. (2015). The impact of language barriers on patient safety and quality of care: Final report. Société Santé en français. https://www.reseausantene.ca/wp-content/uploads/2018/05/Impact-Slanguage-barrier-qualitysafety.pdf
Canadian Indigenous Nurses Association. (2009). Cultural competence and cultural safety in nursing education: A framework for First Nations, Inuit and Métis nursing. https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/first_nations_framework_e.pdf
Canadian Nurses Association. (2017). Code of ethics for registered nurses. https://cna-aiic.ca/-/media/cna/page-content/pdf-en/code-of-ethics-2017-edition-secure-interactive.pdf?la=en&hash=09C348308C44912AF216656BFA31E33519756387
Comité consultatif des communautés francophones en situation minoritaire. (2001). Pour un meilleur accès à des services de santé en français — juin 2001. https://fcfa.ca/wp-content/uploads/2018/03/Pour-un-meilleur-acces-a-des-services-de-sante-en-fran%C3%A7ais.pdf
Consortium national de formation en santé. (2021). Toolbox for the active offer. http://www.offreactive.com/home/
de Moissac, D., & Bowen, S. (2018). Impact of language barriers on quality of care and patient safety for official language minority francophones in Canada. Journal of Patient Experience, 6(1), 24–32. https://doi.org/10.1177/2374373518769008
Patil, S., & Davies, P. (2014). Use of Google Translate in medical communication: Evaluation of accuracy. British Medical Journal, 349(g7392), 1–3. https://doi-org.login.ezproxy.library.ualberta.ca/10.1136/bmj.g7392
Savard, J., Casimiro, L., Benoît, J., & Bouchard, P. (2014). Évaluation métrologique de la mesure de l’offre active de services sociaux et de santé en français en contexte minoritaire. Reflets, 20(2), 83–122. https://doi.org/10.7202/1027587ar
Michelle Leung, RN, is an alumna of the Bilingual nursing program at the University of Alberta. Since her arrival from China to Canada with her family in 2007, she has had to overcome significant language barriers and is thus no stranger to their impacts. Now a speaker of four languages (Mandarin, Cantonese, English, and French), Michelle hopes to use her multilingualism in the clinical setting to enhance patient comfort and facilitate their health-care journey.