Beyond the Language Barrier‘Speak’,‘See’,‘Help Me’

Introduction: King Faisal Specialist Hospital and Research Center (KFSHRC) workforce is composed of close to 67 different nationalities. Diversity in the nursing workforce is unique in the hospital reason being the expatriates outnumber the Saudi nationals. Staff from different backgrounds provides a different perspective to the clinical care ensuring the hospital standards and policies are adhered to. In the Intensive Care Unit (ICU), when these new nurses arrive, their grasp of Arabic is limited. It is essential that nurses understand the language of their patients. In intensive care setting, patient’s condition is critical and highly specialized nursing care is paramount to the safety of the patient. It poses a challenge for non-Arabic speaking nurses to overcome the language barriers, to ensure high quality care is provided to the patient, maintain patient satisfaction and confidentiality. Therefore, communication tool kit is developed to overcome the language barrier. The tool kit is an educational instrument for non-Arabic speakers by expediting learning most frequent terms and words in Arabic. Aim: The purpose of this study is to focus on the importance of implementing a communication toolkit to enhance the communication between the nurse and the patient. Moreover, this study attempted to evaluate the efficacy of this communication tool prepared for non-Arabic health care providers. Method: Descriptive Quantitative pre and post-test study design was used. This study included all adult intensive care units and non-Arabic speaking nurses from KFSHRC in Riyadh. The pre and post questionnaire was developed by a panel of experts working in the ICU. The communication toolkit was created by direct care staff nurses working alongside the multidisciplinary team to address communication barriers. Baseline assessment was conducted which highlighted the common words and culturally appropriate images used by the Arabic patients. After the approval of the ethics and research board the study was conducted. Recruitment of the participants was performed on a voluntarily basis. On the basis of the sample size, 95 percent level of confidence, 73 participants were recruited. The communication toolkit was distributed for the duration of three months. Follow up was performed by the investigators after three a months’ time frame. Results: The results of the study showed that 90 percent of the nurses did not study Arabic prior to their arrival in the hospital. 72 nurses completed the pre and post questionnaires. Majority of the nurses were from Asian countries and few were from Western countries. Most of the nurses were using interpreters to overcome the language barrier. With regards to the questionnaire 94 percent of the nurses viewed that this toolkit will overcome their language difficulties. 19 percent used the toolkit daily, 55 percent used it twice per week and 16 percent used once per month. In regards to the efficacy 83 percent stated that this toolkit is a good mode of communication with the patients. 50 percent of the nurse highlighted the need for Arabic classes. Conclusion: This study highlights the need for the toolkit to improve the language barriers. Most of the nurses have suggested Arabic classes, access to electronic devices and need for interpreters to overcome the language barrier. The toolkit is important and is to be made available in all areas of the organization.


Introduction
Communication is considered as an important patient safety goal [1]. The Joint Commission for Accreditation of Health Care Organizations reported that communication barriers are responsible for almost 85% of sentinel events in hospitals [2]. High quality, patient centered care depends on good communication between health care providers and the patient [3]. In multicultural and multilingual environment, language barriers impose an important challenge to health care providers and patients. This language barrier raises question about the holistic care and collaborative decision making among the patients and health care providers [4]. Studies have highlighted that health care provider-patient communication barrier leads to a decrease in patient satisfaction, potentially poor clinical decision making, increased chances of medical errors, longer hospital stays and poor patient outcomes [1]. However, this risk can be reduced by introducing an interpreter and communicating with patients in their preferred language [5]. Nurses are considered as the primary health care provider for the patient. Patients spend more time with the nurses as compared to other health care professionals. Therefore, it is essential for the nurses that they understand the language of their patients, care for them and competently solve their problems. In intensive care setting, patients are critical and rely solely on nurse's care. Therefore, language is considered as an important means of communication among patient, family and health care providers. It may pose a challenge for non-Arabic speaking nurses to overcome the language barriers, ensure high quality care is provided to the patient and maintain high patient satisfaction.

Background of the Study
The mission of the King Faisal Hospital and Research Center (KFSH&RC) is to provide safe and effective care to patients and their families (King Faisal Specialist Hospital and Research Centre Website). Being accredited by the Joint Commission International Accreditation and Magnet designated, communication is considered as an important area for patient safety [2]. The patients admitted in this hospital communicate in Arabic language. Health care workers are employed from close to 67 different nationalities. Nurses mainly spend majority of their time with the patient. KFSH&RC is a tertiary facility providing highly specialized medical treatments to predominantly Saudi nationals. The hospital has 1549 bed capacity and 10,009 employees. There are 3126 employees working under the Nursing Affairs umbrella; this includes registered nurses, clinical educators, care assistants, patient care assistants and ward clerks (King Faisal Specialist Hospital and Research Centre Website).
In the intensive care unit, when the new nurses arrive, interpreters or the family members are utilized to establish appropriate care plans for the patient. This practice does not maintain the patient's confidentiality or privacy.

Study Purpose
The purpose of this study is to focus on the importance of implementing a communication toolkit to enhance the communication between the nurse and the patient. Moreover, this study attempted to evaluate the efficacy of this communication tool prepared for non-Arabic health care providers.
In particular, this study was designed to answer the following questions: 1. What is the efficacy of this communication tool kit? 2. What was the nurses' level of comfort before and after utilizing this tool kit? 3. What other sources can be used to overcome the language barrier?

Literature Search
A systematic and comprehensive search was done in January, 2014, to access research studies on overcoming language barriers among health care professionals and patients. Various words and phrases were used to guide the search that included: communication, language barriers, language conflict, overcoming language barriers and strategies to reduce language barriers. Data bases such as CINAHL, PubMed, Sage and Science Direct were used to guide the search. The search ranged from 2003 to 2014. A total of 230 articles appeared to be relevant, further reading narrowed down the articles to fifteen that met the study purpose.

Study gap
Literature search highlighted that most of the studies were conducted in the western region and very few in the Middle-eastern region [3,6]. In addition, most of the studies have explored the perceptions and feelings of the health care professionals including expatriates nurses and doctors about caring for patients communicating in different language [7]. Studies have emphasized the use of interpreters [6] but none of the studies focus on the interventions such as communication tool kit to overcome the language barriers. Few studies have focused on using communication boards in ICU [4,8]. Therefore, our study is of the highest important as this will focus on utilizing communication tool kit to reduce this language barrier.

Study Population and Setting
This study included all adult Intensive Care Units (surgical, medical, chronic and cardiac) and non-Arabic staff nurses after obtaining the RAC approval, the duration of the study was three months.

Inclusion criteria
1. Nurses who are non-Arabic were included in the study.

Exclusion criteria
1. Nurses who do not give voluntary consent were excluded. 2. Arabic speaking staff were excluded.

Data Collection Strategies
1. Briefings about the proposed study and its purpose. 2. Recruitment of the participants was done on the basis of voluntarily participation by the participants. 3. Pre-test questionnaire was distributed to the participants who give voluntarily verbal consent to take part in this study. 4. Communication tool kit was distributed and explanations about the tool kit were given to the targeted audience. 5. Participants to use the toolkit for duration of 3 months. 6. Follow up was done by the researchers within the assessment time to reinforce the participants to utilize this tool kit. 7. The participants ID was coded and kept safe with the principle investigator until the publication is done. 8. Post-test questionnaire was redistributed to the participants after three month from the time specified.

Sample Size
Adult ICU nurses who met the inclusion criteria and agreed to participate in the study. In this study, all adult ICU non-Arabic speaking nurses who gave voluntary verbal consent were the part of this study. On the basis of sample size formula with 95% level of confidence, 73 participants were recruited.

Data Analysis
Statistics analysis of data was done by Statistical Package for Social Scientist (SPSS) version 20. Descriptive statistics were obtained for the quality questionnaires and the demographic data and individual questions on the communication toolkit were analyzed.

Ethical Consideration
The principles of confidentiality and respect for human dignity were followed in this study. The study was conducted after obtaining an approval from the Research Advisory Council and according to the ethical principles of the declaration of Helsinki and the Good Clinical Practice Guidelines. To ensure the right of self-determination, the participants were informed that their participation in the research is voluntary and that they had the right to leave the study at any time.
They were also assured that refusal to participate would not have any impact on their job status or benefits. However, voluntary participation of the health care professionals, through an informed verbal consent was taken before the data collection.

Results and Discussion
This part presents an analysis of the findings of the study. This includes details about the questionnaire status, the participants profile, demographics, their level of comfort while speaking Arabic, and their answers regarding the need and applicability of the communication tool kit.

Questionnaire status
A total of 73 participants were enrolled in the study. Only one participant left the study. 72 nurses filled the pre and post questionnaires.

Demographic data
Majority (32%) of the participants enrolled were from Surgical ICU, 19.4 percent from medical ICU, chronic ICU (12.5%) and 35% from cardiac ICU. 89 percent of the nurses recruited were female. Participants' age varied from 25 to 60 years. Most of the participants (62%) were around 26 to 40 years of age. Their education level was diploma and bachelors. 68% of nurses with bachelor's degree were part of this study. Contrary in Al-Harasis [6], 37.9 percent were having bachelor degree in nursing and 3.2% with master's degree in nursing. None of the participants were from gulf region. All of the participants were outside Gulf region. Majority of the nurses were from Asian countries and few were from Western countries (Table 1). This finding is concurrent with other study finding [3] which highlighted that most nurses are from India, Philippines, Malaysia, Australia, America, United Kingdom, South Africa and other Middle Eastern countries with different cultural backgrounds. Almutairi and McCarthy [9] stated that 67.7% of nurses in Saudi Arabia are expatriates.

Level of comfortability while speaking Arabic
As shown in Table 2, only 39 percent were comfortable while caring for Arabic patient and 38 percent ranked their fluency as poor, 41 percent as fair and 15 percent as good. Similarly in Al-Harasis [6], forty nine percent of the nurses stated difficulty in dealing with patient due to the language barrier.
Eighty one percent of the participants were using interpreters and colleagues to overcome their language barriers while caring for Arabic patients and this finding is similar with Al-Harasis [6]. 6 percent were attending Arabic classes to overcome the language barrier. Contradictory, 90 percent of the nurses in Al-Harasis [6] suggested attending an Arabic course especially during the orientation phase. 2 participants highlighted the use of non-verbal communication and 1 shared the use of internet sites for translation. Similarly in Helmsley et al. [10] study, majority of the nurses were using low technology equipment such as boards, pen and paper which is different from our study. In our study, 10 percent were using booklets prepared by the unit for translating commonly used words. Interestingly, 73 percent nurses in Al-Harasis [6] preferred to use the dictionary for quick reference for commonly used words.  In pre-study questionnaire, 94 percent viewed that this communication tool kit will benefit them to overcome the language barrier. 61 percent participants responded it will support them moderately to overcome the language barrier.
Average hours spent using the tool kit 38 percent of the participants used this tool kit twice per week, seventeen percent used it once per week and 7 percent never used the tool kit. 22 percent of the nurses used this tool kit on daily basis or as needed. According to the post questionnaire analysis, 83 percent rated this tool kit as moderate as compared to 13 percent who rated this toolkit as an excellent mode of communication.

Support required and suggestions to overcome this language barrier
Fifty five nurses responded to this question. Majority 50 percent of the nurses highlighted the need for Arabic classes. 2 percent requested electronic devices are made available and accessible to patients. 16.3 percent expressed the need for interpreters. 11 percent identified the need for more communication tool kit accessibility in the units. 4 percent highlighted the need for appreciation. In addition, nurses in the current study raised the matter on who should be the interpreter which is concurrent with Al-Harasis [6] and Timmins [11] study. Timmins [11] suggested hiring trained professional interpreters from the community.

Conclusion
This study has provided information about the need to identify the strategies to overcome the language barrier. In addition, it identifies the nurses' level of comfort speaking Arabic and caring for Arabic patients. Moreover, it highlighted the efficacy and feasibility of this communication tool kit while caring with Arabic patients.

Recommendations
In view of the study findings, following recommendations include importance of:

Limitations
This communication tool kit was advantageous for chronic patients who are alert and orientated. In the ICU the patients were sedated and the toolkit was not utilized. The images and written words in English and Arabic assisted the nurses to communicate with the sedated patient's family members. This study did not test the patients' vital signs and emotional parameters. In future, research focus can be a randomized control trial, evaluate patient responses and see the efficacy of this tool kit on sedated patients. In addition, the plan is to test this communication tool kit in the pediatric population and outpatients.