1. Introduction

Due to the importance of communication in planning healthcare services as well as in diagnosis and treatment procedures, mutual understanding is crucial in clinical encounters, particularly in cases with a language barrier [1]. Regardless of their cultural and linguistic background, all patients are entitled to use an understandable language in contact with their healthcare provider. When patients and healthcare professionals do not share a common language, healthcare professionals have difficulty identifying the patient’s needs. [2,3]. A prerequisite for good cross-cultural communication is an understanding of language and culture as the fundamental elements of all communication. Knowledge of the patient's language and cultural background leads to better understanding of the patient's problems, and thus better communication outcomes [4,5].

In addition to the cultural background of the patient and the healthcare provider, the internal culture of the healthcare system also affects the interaction of healthcare providers with patients who have different linguistic and cultural backgrounds. Western medicine is dominated by a scientific view, which means that the patient's measurable disease is considered most, while the patient's experience of her/his illness is less important. In meetings with patients from other cultures, it is especially important to pay attention to the patient's "illness". Expressions, concepts and values should interpreted and understood in a comprehensible manner. Misunderstandings in interpretation may jeopardize the patient's rights and opportunity to receive the care and assistance that every citizen is entitled to under the healthcare act. A crucial point in communication issues is access to an interpreter as a third person who facilitates communication to overcome the language barrier [6].

2. The Role of the Interpreter as a Language Bridge

When there is a language barrier in communication between patients and healthcare providers, a third person (interpreter) is included to facilitate consultation. Without an interpreter, communication between healthcare professionals and patients who do not share the same language is often difficult and sometimes impossible. In order to prevent misunderstanding in consultation and reach a satisfactory health outcome, the interpreter’s competence is vital. The interpreter should have mastered both the patient’s and the healthcare provider’s languages, as well as have a basic knowledge of differences in cultural expressions in the different societies. Cultural differences may arise in both body language and spoken language [7,6]. Use of an incompetent interpreter, which may eventually result in the loss of relevant information between patient and healthcare provider, could be considered as a threat to patient safety [8]. Assigning an interpreter according to the patient's mother tongue rather than the patient’s nationality has a significant impact on the results of communication [9]. Previous studies have shown that many times the patient’s relative or healthcare professional act as interpreter, even though in emergency cases using a non-professional interpreter could be considered as an alternative that facilitates consultation, in a normal situation personnel or the patients’ relatives should never replace a professional interpreter. Relatives are not neutral, often they do not have language competency and healthcare professionals has no education in interpreting [10-12]. Apart from the interpreter’s competence, practical issues arising during the clinical consultation may influence the outcome of communication. A study by Krupic et al. showed that the lack of time constitutes an important barrier to effective contact and the quality of interpretation [13].

3. Discussion

The growing number of immigrant patients as a result of wars, natural disasters and hunger in many parts of the world poses a challenge to healthcare staff. Since mutual understanding is a prerequisite to an adequate health outcome, in communication with patients with a different language and cultural background satisfactory interpretation is crucial. In order to minimize the risk of misunderstandings in communication during clinical encounters, interpreters should be employed according to the patients’ needs. Assigning appropriate interpreters according to patients’ mother tongue, even, if possible, when it is a dialect, is essential for good communication and patient safety [14,13]. The importance of professional and competent interpreters in clinical consultations in cases when the patient and healthcare provider do not share the same language, has been highlighted by previous studies [15,16,12]. Although in cross-cultural encounters, the interpreters’ competence may be considered to be the main factor that influences the outcome of that communication, there are many other factors that affect clinical encounters, such as: the interpreter’s neutrality, and their ability to maintain the balance between the healthcare professional and the patient during the consultation. Neutrality refers to neutrality in terms of gender, in interpreting and in the relationship (triangle neutrality). Sometimes it is impossible to provide an interpreter of the same gender as the patient, but the question of gender neutrality in clinical consultations through an interpreter should be in the focus of attention, since in some cultures social contact with other genders beyond close relatives is not allowed.

‘‘A female patient once presented with unclear symptoms. Two weeks later, she came back with a female interpreter and hemorrhoids were diagnosed.’’[17].

Neutrality in interpreting means the interpreter does not reduce or add to the original message. Furthermore, cultural related expressions should be interpreted and not simply translated. For instance, the following interaction in a consultation the message, which is culturally related, has been translated instead of interpreted. A client in the social department wanted to say that he had been there a long time but no one had paid attention to him. The expression is culture related and it must interpreted, but because of differences in the mother tongues between the client and the interpreter, the expression was translated, but not interpreted correctly. The message was first translated from Kurdish to Arabic and then from Arabic to Swedish. Finally the message reached the social assistant as, ‘‘I have been sitting in the waiting room for a long time, but no one has asked me how much your donkey costs”. The social assistant asked him in surprise, “Are you selling a donkey here?” [18].

4. Conclusion

Misunderstandings in clinical communication due to linguistic and cultural boundaries, could originate from the interpreter’s insufficient language competence, mother tongue differences in between the patient and the interpreter. The interpreter’s competence and neutrality increase the patient’s confidence, and the interpreter acts as a Language Bridge. Using a professional interpreter, and assigning interpreters according to the patient’s mother tongue rather than the patient’s nationality have a significant impact on the outcome of communication and patient safety.

Competing Interests

The authors declare that they have no competing interests.