Impact of miscommunication

Respondents pointed to a wide range of ways in which barriers in verbal communication created difficulties in health care provision, including difficulties in making a diagnosis, organising operational processes, explaining health conditions, deciding on treatment options and managing follow-up pathways. The relative importance given to each of these problems varied mainly according to the informants’ professional role and duties. The doctors in the sample tended to attach greater significance to the difficulty of exchanging clinical information – which is associated with the diagnostic and therapeutic process – while nurses and health visitors underlined the difficulty of completing administrative procedures as a major problem:

‘When there is a problem in communication, conditions for clinical impasses and medical errors are generated because the transferred information is incomplete or even non-existent.’ [P12, consultant doctor (female), 39 years old]

‘You cannot imagine how difficult it is to explain to someone how to go through the Secretariat, to indicate his name, where to go to take an x-ray or give blood, what is the procedure to get the discharge paper and every other related issue with such kind of procedures. And this load is charged to nurses, without, in fact, (this) being their job.’ [P09, nurse (female), 33 years old]

Many health professionals reported that they usually spend more time during a clinical encounter with an immigrant patient than with a Greek patient with a similar health condition. It was inferred that difficulties with mutual understanding often result in excessive time spent filling the language gaps with repeated questions and subsequent explanations or even with increased number of revisits. Thus, the efficacy of health services and professionals was felt to be significantly reduced in these cases due to the prolonged handling and the delay in processing the cases:

‘… (many) immigrant patients often come back to the clinic either to seek clarifications or because the treatment was not successful. For example, many diabetic immigrants find it hard to understand the instructions for the use of the insulin pen, despite the relevant tutoring … by the health personnel, so they visit the health centre successive times either to re-watch the relevant tutoring or ask the nurse … to administrate the injection.’ [P05, health visitor (female), 44 years old]

The entire procedure of clinical examination was reported to be disturbed. According to many participants, there was a risk that valuable information and important details could leak during the investigation of symptoms, particularly when there is time pressure, but sometimes even when sufficient or excessive time is spent. Therefore, there was a perception among many respondents that the establishment of diagnosis could be difficult and feature inaccuracies, uncertainties and errors, while the treatment may not be completely appropriate, the therapeutic guidelines may not be entirely understood by immigrant patients and the nursing care may not be optimal:

‘… the problems of poor communication can adversely affect nursing care … . I have faced … difficulties in trying to explain (to patients or their companions) how to count the 24-hour urine or understand if they are in pain and at which point.’ [P04, nurse (female), 32 years old]

At the same time, it was reported that the health worker-patient relationship is disrupted as it becomes impersonal:

‘(When the immigrant patient does not speak Greek), I do what I have to do and then I leave. I explain nothing and rely only on the information that I have …’ [P11, nurse (female), 36 years old]

The situation was described as more severe in emergency care departments where there is intense time pressure because professionals manage patients with acute health problems and escorts are often absent:

‘In the emergencies’ department … a great amount of information must be detached from the patient in a relatively short time (and) … the clinical problems are usually urgent and possibly more severe.’ [P02, resident doctor (male), 36 years old]

The problem was felt to be less severe in the regular outpatient departments due to the nature of their operation. Indeed, participants indicated that the examination was conducted after a pre-defined appointment, during which there was available time, and patients usually have sufficient knowledge of the operation of the Greek health care system, so if they do not speak Greek they will have arranged to be accompanied by a person who does.

Several respondents suggested that there was a significant burden on health services from the lack of communication between doctors and foreign patients. Indeed, it was reported that a substantial number of laboratory tests were ordered for the clarification of inaccuracies that arise from the clinical contact:

‘… I am forced to order too many tests, which … could have been avoided if there was a possibility for a better communication with the patient. But there is no other way. … the referral to a series of tests protects the patient and myself from a wrong treatment …’ [P01, consultant doctor (male), 63 years old]

Furthermore, some respondents suggested that the operation of the hospitals’ in-patient clinics was burdened with a greater number of admissions and prolonged hospitalisations of immigrant patients because of failures in diagnosis that arose from the lack of sufficient communication. As a result, it was implied that this situation could

cause significant additional economic costs for the health system and increase staff workload. In general, respondents in this study suggested that poor quality communication with patients from immigrant backgrounds could lead to an excessive consumption of human and material resources within the health system:

‘Especially nowadays, where there is huge resource poverty, overloading the system with unnecessary medical tests is completely unethical … but in the case of immigrants, who do not speak Greek, this is inevitable. … extra work volume is generated in laboratories, resulting in a delay in processing cases.’ [P01, consultant doctor (male), 63 years old]

‘The workload for nurses is huge … and the available time is short and precious. … spending additional time for consultation … creates problems in the timely completion of all the duties … . A lot of times … the nurses of the shift are forced to remain at the clinic for much more time (than the duration of the shift) in order to complete their duties …’ [P04, nurse (female), 32 years old]