When using professional interpreters it is important to ensure that an appropriate interpreter is used, so that communication is patient centred and tailored to the individual. The interpreting guidelines for staff of NHS Scotland state that it is important to know which language or dialect that the patient speaks, and correctly record this in their case notes to ensure continuity of care and reduce delay in accessing appropriate interpreters. If the patient requires a same sex interpreter this should also be noted as some non English speaking women will decline the services of an interpreter who is male, particularly post gynaecological or breast surgery (Blackford and Street cited in Pellatt 2007).
Good discharge planning is both essential to the decision making process in which the patient should be involved and also to the patients long term recovery after surgery. Evidence suggests that providing patients with information and knowledge reduces the instance of readmission and poor outcomes (Mamon at al 1992 cited by Henderson 2001). Presently non English speaking patients are less likely to correctly follow treatment regimes (Oliva 2008) which could suggest they do not always understand the information given or the implications of non compliance.
(Feber 2000; and Dropkin 2001 cited by Bowers 2008) stated that part of the nurses role in post operative care is supporting and teaching patients to undertake self care as patients who have a newly formed stoma or prosthesis will need to learn new self care skills and may be anxious about this. Bowers (2008) concurs and suggests that by involving the patient in their own self care soon after surgery, the nurse can help them to confront and accept impairments, reducing distress and increasing the ability to cope post surgery. To facilitate the teaching of patients with limited English to participate in these new skills may be challenging, as it requires efficient communication and the nurse should be aware of the resources available in the patient’s language to assist with educating and informing the patient adequately as poor resources can be a barrier to communication (Health Scotland 2008). When working with patients who do not speak English, Speirs (2003) suggests that the nurse allocates more time to make sure that the patient fully understands the information being given. She also recommends that clear, slow and consistent language is used in conjunction with pictures, word cards and appropriate literature. When providing written information in the patient’s language it should be remembered that some patients may also have literacy difficulties (Bradby; Panesar and Sheik cited in Pellatt 2007). Patients often use verbal communication to seek reassurance from nursing staff, and many patients express the need to feel cared for in both a medical and surgical setting. Both verbal and non verbal communication has been reported to convey care and reassurance to patients effectively (Fareed 1995). Facilitating therapeutic communication with patients has a positive impact on the patient’s satisfaction of their care (Roter 2004) as patients perceptions of the outcomes of surgery are not simply based on its physical success, but also upon its psychosocial impact (Allan 2003). This is particularly relevant in a post operative setting where many patients undergo surgery which can be seen as disfiguring or distasteful such as mastectomy, facial surgery or stoma formation. The impact of this may vary from culture to culture, however the need for reassurance is common to most affected patients. Since the patient with limited or no English will be unable to seek reassurance verbally, patients self image after surgery can be greatly influenced by the nurses non verbal reaction towards a perceived disfigurement, particularly after reconstructive or facial surgery. Where the nurse is unable to communicate in the patient’s language, facial expressions and other non verbal gestures can be used to convey a positive attitude towards the patient’s appearance. The nurse can show acceptance of how a patient looks by maintaining good eye contact and by giving positive feedback and unhurried responses (bowers 2008). Non verbal cues can convey strong negative or positive attitude towards a patient who cannot understand English, something of which the nurse should be aware of, and use to reassure the patient. (Hamilton and Essat 2008).
Often patients respond well to empathetic gestures such as touch and where appropriate these can relieve distress. Graham (2003) states that the nurse should observe the patients cues and ensure that the patient feels valued and cared for, as distress and isolation can be a further barrier to communication, especially if a patient becomes withdrawn. In addition, Morse et al cited in Graham (2003) maintains if the nurse has a very basic grasp of the patients preferred language, such as greetings, they can help facilitate communication by showing that they are making the effort which can ease the patients anxiety and feelings of isolation (Bradby cited in Pellatt 2007). Communication strategies employed by nurses such as these can have a positive impact on the patients post operative recovery (Sharples 2007) while maintaining trust and increasing patient’s willingness to seek out communication with the nurse.
In post operative patients, the need to communicate pain effectively is essential to avoid unnecessary suffering and distress. Under medication is common among postoperative patients, particularly when the patient has difficulty communicating with nursing staff due to a language barrier therefore the nurse needs to plan strategies to overcome this (Grey 2005, Mackintosh 2005 cited by Layzell 2008). Communication strategies suggested by Ward and Morris (2003) to avoid poor pain management of post operative pain are: talking to the patient; listening to and respecting the patients point of view while using appropriate pain assessment tools. The challenge facing the nurse of a post operative patient who does not speak the same language is that a third party is required to aid these strategies, and the nurse must decide if a professional translator is necessary. Heptinstall et al (2004) asserts that this type of interpretation is not always easy to arrange at short notice, therefore it may be useful to make use of the NHS telephone interpreter service available in all NHS hospitals. Nurses are obligated to provide an equally good standard of care for all patients (Ledger 2002) therefore they should identify communication difficulties as a risk factor for under management of post operative pain (Layzell 2008). Poor management of pain can lead to post operative complications as pain reduces mobility making the patient more vulnerable to complications such as blood clots and chest infections (Ward and Morris 2003). Pain also disturbs sleep needed for effective immunity (Arnstein 2002 cited in Layzell 2008) and when pain is not assesses and managed effectively, the patient may spend longer in hospital becoming more vulnerable to further complications and infection (MacIntyre and Ready 2002 cited in MAcKintosh 2007). It could be argued that since poor communication increases anxiety and distress which can heighten the sensation of pain (Melzack 1965 cited by Morrison and Bennett 2006; Vaughn et al 1995 cited 2008), lower immunity and delay healing (Keicolt-Glaser et al 1995 cited in Layzell 2008) that effective communication plays an important part of the physical recovery of the patient.
Another communication need that has to be taken into consideration is the expression of preferences and choices. The NMC (2008) requires nurses to treat patients as individuals, but facilitating these choices can also have a positive impact on the patient’s health. For example, Wynia and Matiesk (2006) discuss a patient who refused food for a number of days until an interpreter became available, once communication was established it became clear that the patient was willing to eat, but not food that was unfamiliar to him. It could be argued that in such circumstances, particularly in post operative care where nutrition is important to recovery and healing, that since a professional interpreter is unlikely to be accessed for this type of communication an ad hoc interpreter may be appropriate.
The use of non professional interpretation, such as family, friends and bilingual staff may be acceptable for informal and day to day discussion raises few ethical issues, however using untrained interpreters for health related issues or discussing care is accompanied by legal and professional challenges for nurses and disclosure implications for patients as the nurse must respect the patient’s right to confidentiality (NMC 2008) but ad hoc translators are not bound by professional or legal codes of confidentiality like professional trained translators. The use of children is never recommended since they may lack the maturity to understand what is being communicated, may become distressed and the patient may be unwilling to disclose information through a child (Health Scotland 2008). Furthermore the nurse is required to disclose information that the patient requests about their health and treatment (NMC 2008) but cannot be sure that this information is being translated correctly to the patient (Black 2008). Where a patient refuses the services of a translator this should be recorded (Health Scotland 2008)
In conclusion, effective communication impacts on the quality of care which nurses provide post operatively, and how the specific needs related to of post operative patients are met. In the case of Adults with limited or no English, it raises ethical, professional and legal issues and challenges for meeting the patient’s communication needs; however it is clear that by planning and implementing strategies to overcome language barriers, the nurse can have a positive effect on this patient groups post operative outcomes.
References.
Allan (2003) Ch 10, Culture : the social context of surgery. Surgical nursing: advancing practice. London. Elsevier.
Black, P (2004) Psychological, sexual and cultural issues for patients with a stoma. BritishJournal of nursing. Vol 13,pp. 692-697
Black, P (2008) A guide to culturally appropriate care. Gastrointestinal nursing. Vol 6, pp. 10 – 17
Bowers,B (2008) Initiating self care. British Journal of Nursing. Vol 17,pp.94-98
Hamilton.,M and Essat., Z (2008) Minority ethnic users experiences and expectations of nursing care. Journal of research in Nursing. Vol 13, pp. 102-110
Heptinstall, T et al (2004) Asylum seeker: a health professional perspective. Nursing standard. Vol 18 ,pp. 44-53
Layzell,M (2008) Current interventions and approaches to postoperative management. British Journal of nursing. Vol 17,pp. 414-419
Ledger,S (2002) Reflections on communicating with non English speaking patients. British Journal of nursing. Vol 11, pp. 773-780
MacKintosh, C (2007) Assessment and management of patients with post operative pain. Nursing Standard Vol 22, pp.49-55
McCabe, C (2004) Nurse-patient communication: an exploration of patients’ experiences. Journal of clinical nursing. Vol 13. pp. 41-49
National resource centre of ethnic minority health (2008) Now we’re talking. Interpreting Guidelines for Staff of NHS Scotland. NHS Health Scotland. Edinburgh.
Nursing and Midwifery Council (2008) The Code. Standards of conduct, performance and ethics for nurses and midwives. London.
Oliva, N (2008) When language intervenes. Advanced Journal of nursing. Vol 108. pp73-75
Pellatt, G (2007) The provision of culturally appropriate care for individuals with spinal cord injuries. British Journal of Neuroscience nursing. Vol 3.pp 366-371
Race Relations (Amendment) Act 2000
Roter, D (2004) Patient centred Communication. British Medical Journal USA. Vol 4, pp. 280.
Speirs (2003) Ch.3. Surgical nursing:advancing practice. London.Elsevier.
Ward and Morris (2003) Ch22, Principles of post operative care. Allan (2003) Ch 10, Culture : the social context of surgery. Surgical nursing: advancing practice. London. Elsevier.
Wynia., M and Matiesk.,J (2006) Promising practices for patient centred communication with vulnerable populations: Examples from eight hospitals. The Commonwealth Fund.
Bibliography.
Cioffi, J (2003) Communicating with culturally and linguistically diverse patients in an acute care setting: nurses’ experiences. International Journal of Nursing Studies. Vol.40.pp. 299-306
