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Breaking down barriers

Nurses working in all settings will encounter patients with cultural or language differences to which they must be sensitive

It's normally reckoned there are around 6,000 languages spoken in the world, and in modern Britain - at least, modern urban Britain - it sometimes seems you can hear most of them just by wandering through the city centre on a Saturday afternoon. Walk into a large NHS Trust in any large city and look at the staff, and this too is a reminder of the global village we inhabit. For those of us brought up in a monolingual and monocultural environment speaking only English, it's a reminder that familiarity with and exposure to only one language is the exception rather than the rule.

But the multilingual and multicultural world brings challenges too. How do we work together, and support each other, if we struggle to make sense of each other's worlds?

In general practice, the crunch point is often that patients and healthcare professionals do not speak the same language. This may, in some environments, be comfortably handled by employing a couple of speakers of the predominant local language; but in other areas, the number of languages used by the patient population far outstrips the capacity of the practice to employ speakers of the languages.

Every practice has stories of the family member translating for the mother who is too embarrassed to discuss her period problems in front of her son. Or the husband who tells the nurse what he thinks the issue is, not what his wife thinks it is.

Idioms also translate very poorly; I recall hearing a Chinese-speaking doctor once earnestly talking about the need for seatbelts, otherwise the steering wheel might crush your chest - and you will die of a broken heart.

Different languages do things differently, and behind them, different cultures do things differently too. There are large areas of misinterpretation possible here: the South Asian patient who sits with courteously downcast eyes and is misunderstood as having, as psychologists say, a flat affect. And it can be a problem for nurses too, even in non-clinical areas. Some may seem to be “rude to patients” when they aren't - it's just that, culturally, they might be

'The crunch point is often that patients and healthcare professionals do not speak the same language'

more honest, more straight, and more willing to speak their minds. There are cross-cultural issues with large parts of the communication system, such as the expression of authority, or courtesy, or deference. This also means, often, capturing the way lay people describe nebulous feelings about symptoms to do with such areas as mood, or mental health. Often what is crucial here (thinking again of the patients whose hearts are literally broken) is the extent to which a concept like voices in the head is to be taken literally or metaphorically.

How can risk be mitigated? The fact is that there may, at a particular practice, be dozens of first languages among the patient population, and it is obviously inconceivable that they can all be covered by staff. This is where a good translations service comes into its own, and it is at this stage that the value to patients, and the cost-effectiveness of the service, come into their own.

In addition to this, however, there is something much more tenuous. The stereotypical monolingual Brit, traditionally, shouts loudly at foreigners on the grounds that if they do so they'll get through to them. A person like this, basically, can't quite grasp the idea that people actually may not understand English. The truth is, though, that this is a stereotype with a grain of truth in it.

For the monolingual, it can be difficult to make the mental leap into a world of other languages, other ways of thinking. It takes effort and exposure and a deal of reflection to help the penny drop. Making that internal effort can be a great help - even if we don't speak all or any of the languages we might here in our practice, we can at least understand what it is to be in another country, coping with the level of difficulty that not speaking a language entails.