The significance of communication and care in one’s mother tongue: Patients’ views

Introduction

Clear communication in healthcare is important for patients, ¹ and nurse–patient communication is crucial to maintaining the quality of care.^2–5 When nursing staff and patients do not speak the same language, serious communication problems may arise,^6–8 which can also jeopardize patient safety and patients’ experiences of good care.^9–16

Aims

The aim was to explore the importance of patients receiving care in their mother tongue.

Theoretical perspective

A language policy perspective was assumed in this study. According to Thomason and Kaufman, ‘languages are a product of, and a vehicle for, communication among people’.^41(p.4) The Office of the United Nations High Commissioner for Human Rights (OHCHR) ⁴² stated that language is key to social inclusion and can be seen as the centre of human activity, self-expression, identity and culture and must consequently be protected and respected. ⁴² Henderson et al. ⁴³ found that because communication entails context and interaction, language skills are complex and socially constructed.

There are an estimated 5000–6000 languages in the world, yet according to Piller only 15 languages account for the overwhelming majority of Wikipedia entries: of these there are 2.5 times more entries for the first-most frequently used language, English (4,948,736), than for the second-most frequently used language, Swedish (1,974,655). ²² In the European Union (EU), language diversity and aspects of societal and individual multilingualism have been given rather high consideration, ⁴⁴ and minority languages are seen as a valuable part of the cultural and linguistic heritage of the EU. ⁴⁵ The European Charter for Regional or Minority Languages (ECRML) was drawn up in 1992 ⁴⁶ with the intention to preserve linguistic diversity throughout the EU and call attention to language planning concerns at the highest level, ⁴⁵ even though its underlying purpose is nevertheless considered to be cultural. ⁴⁷ In the ECRML it is stated that, ‘the protection of the historical regional or minority languages of Europe, some of which are in danger of eventual extinction, contributes to the maintenance and development of Europe’s cultural wealth and traditions’.^46(p.15) Also, ‘the charter sets out to protect and promote regional or minority languages, not linguistic minorities’.^46(p.16) In 2003 the European Commission launched the Action Plan 2004–2006, with the purpose of promoting language learning and linguistic diversity and this, along with other initiatives, has been considered one of the most important processes in the EU’s history and a turning point for the EU’s language policy. ⁴⁵

The promotion and protection of the identities of linguistic minorities is perceived as being central to the rights of minorities, and as such is also important with regard to a person’s private life, identity and dignity. ⁴⁵ According to the OHCHR, ‘“language rights” and “linguistic human rights” are human rights which have an incidence on language preferences of or use by state authorities, individuals and other entities’.^42(p.4) Arzoz, ⁴⁷ referring to Foucher, found that the idea underlying the recognition of language rights was to protect specific linguistic minorities, not every linguistic minority, and/or secure equal status for specific languages, not every language. While various recommendations for how the linguistic rights of national minorities can be secured exist, one can nevertheless conclude that, despite some differences, there are norms; the recommendations are all comparable and include central principles with regard to the language rights obligations of state authorities. ⁴² According to the OHCHR, the private sphere is one of the most significant areas of language rights, ‘where individual freedoms and other rights in international human rights operate to guarantee linguistic freedom in private matters’.^42(p.10) Researchers have found that even the most indigenous language minorities in the EU still face losing linguistic ground in relation to the surrounding majority language, no matter how active said minorities are. ⁴⁸ Some ‘old’ minority languages are solely used in a single European state, e.g. Welsh, and such languages can be considered ‘unique’, historical minority languages. ⁴⁴ Other minority languages are used in more than one European state, with some languages being a minority language in one state yet a majority or national language in another state (or vice versa), e.g. Swedish, Dutch, French and German. ⁴⁴ Some researchers have maintained that the minority or majority status of a language community depends on a specific (political) context. ⁴⁹ Arzoz maintained that language rights, according to Green, can be perceived as:

… special guarantees accorded to citizens as a ‘natural’ dimension of state-building or re-building, or as part of a legitimacy bargaining a post-dictatorial or post-racist state needs to make: if the state wants to have citizens’ trust, it has to provide for language rights. Thus, language rights are compromised rights of a fundamental sort.^47(p.23)

In Finland, for historical reasons, both Finnish and Swedish are official languages. If one looks more closely at the Constitution of Finland, with regard to a citizen’s right to language and culture, it is stated under ‘Basic rights and liberties’ that:

1) The national languages of Finland are Finnish and Swedish. 2) The right of everyone to use his or her own language, either Finnish or Swedish, before courts of law and other authorities, and to receive official documents in that language, shall be guaranteed by an Act. The public authorities shall provide for the cultural and societal needs of the Finnish-speaking and Swedish-speaking populations of the country on an equal basis.^47(p.29)

Method

Participants

The participant group was heterogeneous and consisted of nine Swedish-speaking Finns, whose mother tongue was Swedish and who had experience of hospital stays in Southern Finland. This study differs from other research on language barriers because the participant group consisted of individuals who were not only minority-language patients but also members of an indigenous minority. In a socio-economic sense, comparison can perhaps best be made to the French Canadians. In this study, the term ‘majority language’ was used to denote the Finnish language while the term ‘minority language’ was used to denote the Swedish language. For more information about the participant characteristics, see Table 1.

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Table 1.

Characteristics of the participants.

Participant	Sex, age	Marital status	Work/education	Hospital experience	Hemort	Retired/ working
P1	Female, 71 years	Married	Economist. Has worked in theatre.	Hip surgery spring 2018.	Helsinki	Retired
P2	Female, 68 years	Married	Has worked in insurance.	Hip surgery spring 2018.	Vanda	Retired
P3	Male, 63 years	Cohabiting	Has worked as seaman, entrepreneur and in the national telephone answering service.	Hip surgery spring 2018. Many other joint surgeries before.	Helsinki	Retired
P4	Male, 73 years	Married	Machine engineer. Has worked as consultant.	Memory examination, doctor’s appointments approximately once a month.	Helsinki	Semi-retired
P5	Male, 66 years	Married	Economist. Has worked in TV production, and as teacher and school principal.	Knee surgery summer 2018. Ischemic stroke about ten years ago.	Helsinki	Works as a school principal.
P6	Male, 65 years	Married	Librarian. Majored in history.	Appendectomy a few years ago.	Esbo	Retired
P7	Female, 77 years	Single	Nurse aid. Has worked in hospital administration.	Has worked in the hospital all her working life. Hip joint operation summer 2018.	Helsinki	Retired
P8	Female 65 years	Married	Librarian. Has worked in a library.	Given birth in the hospital. Has accompanied family to hospital.	Esbo	Works as a librarian.
P9	Female, 27 years	Dating	Economist. Works as consultant.	Clot in the lung a few years ago. Hip operation.	Helsinki	Works as a consultant.

In 2018 the total population of Finland was estimated at approximately 5.5 million. The two main official (national) languages are Finnish and Swedish, even though Swedish-speaking Finns are classified as an ethnic minority. Finnish is the majority language, and 4,835,778 individuals were registered in 2018 as having Finnish as their mother tongue. ⁵² In addition to Finnish and Swedish, several other languages are spoken in Finland, e.g. Russian, Arabic, Estonian, English, Somalian and Kurdish. ⁵²

Swedish-speaking Finns constitute a significant portion of the population, numbering approximately 300,000, and are classified as an ethnic minority. ⁵³ They form the largest minority group in the Nordic countries. In contrast to many other ethnic minorities, Swedish-speaking Finns are seen to be healthier, more prosperous, and have greater life expectancy than the majority population. ⁵³ Because Swedish is an official language, Swedish-speaking Finns have the right to receive services in their own language. Furthermore, in those municipalities where at least 8% of the population or at least 3000 individuals are registered as Swedish-speaking, state/municipal services in the Swedish language are guaranteed. ⁴²

Patients’ right to service in the national languages of Finland, in accordance with own language (mother tongue) is emphasized in the Language Act (423/2003), ⁵⁴ the Constitution of Finland (731/1999) ⁵⁵ and the Act on the status and rights of patients (785/1992). ⁵⁶ In Section 3 of the Act on the status and rights of patients (785/1992), ⁵⁶ it is stipulated that a patient’s mother tongue, individual needs and culture must, to the extent possible, be taken into consideration during care and/or treatment. Furthermore, a patient has the right to use, be heard in, and obtain documents containing decisions in the Finnish or Swedish language as well as the right to interpretation when using these languages or translation if the language of an authority or the language of proceedings is different, rights that are also mentioned in Sections 10, 18, and 20 of the Language Act (423/2003). ⁵⁴ In Section 6 of the Health care Act (1326/2010), ⁵⁷ it is also emphasized that local and joint municipal authorities shall make healthcare services available in Finnish or Swedish, with certain provisions made for whether a municipality is considered unilingual or bilingual.

Data analysis

Initially, both researchers read the data several times with openness. Such reading resulted in the finding of data similarities and differences that transformed the researchers’ understanding. Various meaning units in the data were highlighted and compiled in a table, in which the researchers’ thoughts on the data’s condensed meaning units, codes, subthemes and main theme were reflected. For an example of this process, see Table 2. The interpretation was a movement between interpretation and understanding, and between the whole, the parts and the whole in a spirit of hermeneutics. ⁵⁰ The researchers’ pre-understanding was carefully formulated during the interpretation to prevent it from steering the interpretation and was challenged and invited into the scientific dialogue during the reading to elicit a new horizon of understanding. The data were first analysed separately through individual analysis, followed by the researchers jointly agreeing upon final analysis and abstraction through consensus.

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Table 2.

An example of the data analysis process.

Meaning unit	Condensed meaning unit	Code	Subtheme	Main theme
At first things went straight to hell. Then after two weeks she received care in Swedish. And from then on, things really improved … And then a nonchalant behaviour from a doctor who obviously only spoke Finnish, threw her papers on her stomach. Used it as a table so to speak. That made me very sad, but it was perhaps not the time to ask the doctor to remove the papers, that it is her stomach, and very disturbing to see. What an attitude!	Not receiving care in the patient’s own mother tongue does not improve his or her health Nonchalant and insulting behaviour from a doctor	Violation, suffering due to care	Being treated with dignity provides wellbeing and hastens recovery time	Quality of care may be enhanced through care in one’s mother tongue

Results

One main theme and four subthemes emerged from the findings. The main theme was ‘Quality of care may be enhanced through care in one’s mother tongue’. The subthemes were: ‘Being understood and understanding in a caring situation provides an increased sense of security’, ‘Being allowed to be oneself eases the patient’s cultural existence and strengthens communication’, ‘Being treated as equal decreases suffering related to care and gives the patient strength’, ‘Being treated with dignity provides wellbeing and patients feel they recover faster’ (see Table 3).

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Table 3.

Main theme and subthemes.

Main theme	Subthemes
Quality of care may be enhanced through care in one’s mother tongue	Being understood and understanding in a caring situation provides an increased sense of security
	Being allowed to be oneself eases the patient’s cultural existence and strengthens communication
	Being treated as equal decreases suffering related to care and gives the patient strength
	Being treated with dignity provides wellbeing and patients feel they recover faster

Discussion

The aim of this study was to explore the importance for patients of receiving care in their mother tongue. We found that receiving care in one’s mother tongue was connected to quality of care. Receiving care in one’s mother tongue was crucial for patients’ sense of safety and eased their cultural existence, and the realization of such presupposed nurses’ cultural and ethical competence. ²⁸ We saw that patients’ sense of safety and trust in the care being provided increased when nursing staff accommodated patients in their need to receive care in their mother tongue, even if the nursing staff’s proficiency in the patients’ mother tongue was lacking. It is essential that nurses express themselves in a language that patients understand. ⁵⁹ Patient trust in the care being provided is important with regard to whether patients accept the care being offered, and over time this can contribute to the quality of care. ¹⁸ Nevertheless, Sze-Mun Lee et al. ³⁹ emphasized that there are risks (e.g. misunderstandings, care errors) associated with nursing staff using simplified language with patients, which often occurs with minority-language patients, and even vice versa, when patients use simplified language with nursing staff. ³⁹

Researchers^33–35 have found previously that the use of professional interpreters can generally be considered a good, cost-saving and care-improving measure and that using professional interpreters is even better than nursing staff using limited language skills. Still, we maintain that the use of professional interpreters might not be solely positive in contexts similar to the context seen in this particular study: a country with two official languages and where majority and minority language speakers are afforded equal language rights. ⁴⁷ While patients can receive care in their mother tongue either via nursing staff or professional interpreters, this does not guarantee or even imply that minority-language patients then receive advanced care in their mother tongue. We maintain that the optimal situation would include the provision of care by nursing staff who are proficient in both the majority and minority languages and who possess specialized language skills. Other researchers have found that if only a few nurses or a single nurse possess both specialized language skills (context-specific and which facilitate communication with minority-language patients) and advanced nursing skills, this can affect the nurse-to-nurse care relationship in a unit. ⁹ We therefore recommend that arrangements be made so as to ensure that several such specialized and highly skilled nursing staff are working at all times.

We saw that the participants perceived that it could be necessary to not speak their mother tongue and instead speak the majority language used by nursing staff, e.g. when nurses’ knowledge of the minority language was insufficient. The risk of misunderstandings increases when patients use a language other than their mother tongue.^18,21,60 Previous studies have shown that the more serious the illness the more important it is for patients to express themselves in their mother tongue.^18,61 When there are time pressures and it is difficult to find the right words, patients can feel unsafe and their anxiety can increase. Misdiagnoses can also increase when nurse–patient communication is compromised. ⁶¹ Not being understood and not understanding can be considered suffering related to care, where patients feel unsafe, sad, shameful and alone. ⁶² Suffering in care can, in turn, lead to a worsening of patients’ symptoms of illness. ⁵³ When patients feel that their mother tongue is respected by nursing staff, patients’ feelings of loneliness and alienation can decrease. We saw here that the participants often experienced suffering related to care and could feel that their rights were compromised when they did not receive care in their mother tongue. Language barriers can result in patients perceiving a person speaking another language as being terse or rude, ¹⁸ because language touches upon a significant emotional dimension and helps preserve personal and linguistic identity.^42,47 The participants in this study maintained that they could experience a sense of not being equal in the care relationship when using their mother tongue and that nursing staff did not take them seriously when a lack of skill in the majority language, which the nursing staff spoke, was admitted.

Patients in Finland have the right to service in the national languages of Finnish and Swedish, in accordance with their own language (mother tongue), as emphasized in the Language Act (423/2003), ⁵⁴ the Constitution of Finland (731/1999) ⁵⁵ and the Act on the status and rights of patients (785/1992). ⁵⁶ In the healthcare context in Finland this includes more than the right to receive information about one’s care in one’s mother tongue (often via professional interpreter), as is seen in other countries where minority languages are not granted ‘official language’ status. Finland presents a special case because of its two official languages: while Finnish-speaking healthcare staff are not required by law to speak Swedish with Swedish-speaking patients, Swedish-speaking Finns have the right to speak Swedish with all healthcare staff.^54,56 Therefore, not receiving care in Swedish can lead Swedish-speaking Finns to perceive that their rights are being compromised and that they as human beings are not being treated with dignity, when they are misunderstood, not taken seriously or not treated as equal to those who speak the majority language. ⁴⁷

Overcoming linguistic difficulties by using professional interpreters is, in a setting such as seen in this study, therefore problematic. Granhagen Jungner et al. ⁴⁰ found that translating and transferring information is problematic, because cultural issues can lead to cultural misunderstandings and clashes. Also, acting as a neutral interpreter in a situation where a cultural link is needed is difficult, because interpreters may ‘context adjust’ their translations. ⁴⁰ Moreover, Bischoff et al. ⁶ saw that interpreters also take into account wider cultural and political contexts rather than solely translating word-for-word. In a healthcare context, interpreters must have the understanding and ability to handle cultural divergences between staff, patients and families. ⁴⁰ Bischoff and Hudelson ⁶³ suggested that language services should be integrated into healthcare organizational routines to address any eventual problems that clinical staff may have with regard to interpreters.

The caring relationship is compromised when patients perceive that they have been treated in an offensive way, seen in this study as next of kin perceiving that they needed to ‘demand’ that nursing staff provide care for patients in the patients’ mother tongue. Patients can experience shame if they cannot speak the majority language sufficiently well, which, in turn, causes suffering related to care. Patients can also begin to question their condition and even whether they need care at all, which, at worst, can lead to hesitation in seeking help, so as to avoid language problems and shame. The harmful experience of not being treated as equal in the caring relationship has a profoundly negative effect on patients’ wellbeing and health, and nursing staff should recognize that minority-language patients are vulnerable in the caring relationship. Alpers ²⁵ found that discrimination in healthcare occurs and that it can lead to racial and ethnic health inequities that negatively affect health outcomes.^64,65

Allowing patients to receive care in their mother tongue helps preserve patients’ identities and can ease patients’ cultural existence. Patients can be themselves when speaking their mother tongue and be seen as a whole human being, which in turn strengthens communication in the caring relationship because it helps patients express themselves and their needs more precisely. When patients are allowed to speak their mother tongue, non-verbal communication is also supported and more evidently contributes to understanding. Sze-Mun Lee et al. ³⁹ saw that non-verbal communication can easily lead to misunderstandings because, e.g. a gesture can mean different things depending on cultural context. Also, Züllich et al. ⁶⁶ found that when nursing staff and patients share the same mother tongue and linguistic culture, the patients’ culture is taken into consideration and nurses’ non-verbal communication is more understandable for patients.

As seen here, speaking one’s mother tongue allowed patients to feel recognized, seen and as though they were equal. It allowed them to to experience dignity in the caring relationship, which positively influenced their recovery and improved perceived quality of care. Not receiving care in one’s mother tongue could cause discontent, worry, and a sense of feeling unsafe. Taylor et al. ³¹ found that when an individual is subjected to stress, he/she often finds it difficult to understand and remember instructions. Consequently, when nurses cannot speak a patient’s mother tongue, a personal and loving presence becomes even more meaningful. ⁶²

To improve the quality of care and ensure that patients can receive care in their mother tongue, those who employ nurses should consider language skills to be an important attribute. Truong et al. ²⁸ suggested that it would in certain instances be appropriate to hire healthcare staff from various ethnicities and minorities, because such employees can possess valuable knowledge of their own culture and consequently better understand patients from the same culture. If nurses have good knowledge of a minority language, this can imply that they also have a positive attitude toward that particular language. ³⁷ Healthcare organizations should support nurses by organizing for them language courses in a country’s minority language, because such courses are useful in positively changing negative attitudes toward a minority language. ³⁷

This study also shows that patients were made vulnerable and that their autonomy was compromised when their next of kin were asked to act or acted as language brokers. According to Sze-Mun Lee et al., ³⁹ having next of kin as language brokers may be problematic in caring situations, because confidential and sensitive matters may be revealed which would compromise confidentiality and patients’ right to dignity. Also, if language brokers are dominant and excluding in their roles^67,68 or ‘speak as themselves’ rather than accurately transferring information,^67–69 they can have a negative effect on the caring relationship.

Receiving care in one’s mother tongue entails being treated with dignity and seen as a whole person. ⁶² Being included by health professionals can instil patients with courage and inner strength ⁷⁰ as well as confidence and trust. ⁷¹ Respectful treatment, where caregivers are kind and create space for patients and their next of kin to participate in care, results in patient satisfaction with care. ⁷² According to Eriksson, ⁷³ poor treatment or lack of eye contact may extinguish a patient’s last spark of joy. Being forced to translate or search for words in a second language is tiring, especially if one has a serious illness. Earlier research shows that even if nursing staff can only talk about everyday matters in a patient’s mother tongue, this helps create a good nurse–patient relationship. ³⁷ Related to this, a new finding was seen in this study: that patients’ next of kin also experienced it as being tiring when patients did not receive care in their mother tongue.

As seen in the results, quality of care may be enhanced through care in one’s mother tongue. The participants clearly perceived that care in one’s mother tongue provided a sense of safety, improved communication and understanding and contributed to patients’ wellbeing and strength. Also, we saw that using patients’ next of kin as language brokers should be avoided, because this can compromise the wellbeing and dignity of both patients and their next of kin.

Conclusions

Receiving care in one’s mother tongue leads to the perception of quality of care for patients and their next of kin, and the realization of such presupposes nurses’ cultural and ethical competence. Supporting nurses’ language skills and encouraging them to use these in care are important means whereby suffering related to care resulting from language barriers can be reduced. Further research should focus on nurses’ perspectives on the significance of minority-language patients using their mother tongue in a nursing context.