ARTICLE IN PRESS

0020-7489/$ - se

doi:10.1016/j.ijn

�CorrespondE-mail addr

International Journal of Nursing Studies 44 (2007) 1177–1186

www.elsevier.com/locate/ijnurstu

Language awareness in the bilingual healthcare setting:A national survey

Gwerfyl Wyn Robertsa,�, Fiona Elizabeth Irvinea, Peter Reece Jonesa,Llinos Haf Spencera, Colin Ronald Bakerb, Cen Williamsc

aSchool of Nursing, Midwifery and Health Studies, University of Wales, Bangor, Gwynedd LL57 2EF, UKbSchool of Education, University of Wales, Bangor, Gwynedd LL57 2DG, UKcCanolfan Bedwyr, University of Wales, Bangor, Gwynedd LL57 2DG, UK

Received 29 November 2005; received in revised form 27 March 2006; accepted 30 March 2006

Abstract

Background: The significance of effective interpersonal communication in healthcare is well established, as is the

importance of overcoming language barriers. This has a particular bearing for minority language speakers, where

denying language choice can compromise the quality of healthcare provision. Nevertheless, there is limited empirical

research exploring language awareness in healthcare and the factors that influence language choice for minority

language speakers.

Objectives: This paper reports on the nurses, midwives and health visitors (NMHV) data set of the first phase of a

large-scale national study, commissioned by the Welsh Assembly Government, to examine the nature and extent of

Welsh language awareness amongst healthcare professionals in Wales, UK.

Design: The study involved a questionnaire survey of healthcare professionals working in the public, private and

voluntary sectors of healthcare.

Participants: A stratified random sample of 3358 healthcare professionals was surveyed, of which 1842 (55%) were nurses,

midwives and health visitors. The researcher-designed self-administered questionnaire was distributed by post to participants

between July and September 2003. A total of 1042 (57%) NMHV returned their questionnaires for analysis.

Results: A strong positive correlation is identified between the NMHV use of the Welsh language in practice and their

Welsh language proficiency (po:01); language attitudes (po:01); and language region (po:01). Mean language attitude

scores are more positive than expected, particularly amongst those with limited Welsh language proficiency and those

working in regions with the lowest proportions of Welsh speakers.

Conclusions: In view of the universal drive for culturally and linguistically appropriate healthcare practice, the findings

have important implications for bilingual and multilingual healthcare settings worldwide. The evidence emerging from

this survey confirms that cross-cultural communication is enhanced by NMHV language attitudes as well as their

proficiency levels. Language awareness training is therefore recommended as a way of enhancing care delivery for

minority language speakers.

r 2006 Elsevier Ltd. All rights reserved.

Keywords: Attitude; Bilingual; Communication barriers; Language; Structured questionnaires; Welsh

e front matter r 2006 Elsevier Ltd. All rights reserved.

urstu.2006.03.019

ing author. Tel.: +441248 35 5151; fax: +441248 38 3114.

esses: gwerfyl.w.roberts@bangor.ac.uk (G.W. Roberts), l.spencer@bangor.ac.uk (L.H. Spencer).

ARTICLE IN PRESSG.W. Roberts et al. / International Journal of Nursing Studies 44 (2007) 1177–11861178

What is already known about the topic?

�

Language barriers in healthcare can delay and

compromise the quality of care and treatment.

�

Offering language choice to minority speakers facil-

itates the communication process and enhances

healthcare delivery.

�

There is a paucity of empirical research exploring the

factors that influence language awareness amongst

nurses and the way in which they facilitate language

choice for minority language speakers.

What this paper adds

�

Language awareness amongst nurses, midwives and

health visitors is influenced by their language

proficiency and attitudes in practice.

�

Despite varying degrees of language proficiency,

many nurses, midwives and health visitors are

sensitive to patients’ communication needs and

endeavour to use the patients’ language, particularly

within a social context.

�

The study highlights important implications for the

development of language awareness training that

reflects the needs of minority language speakers

across bilingual and multilingual communities.

1. Introduction

The importance of effective communication in

healthcare has long been established and lies at the

heart of healthcare delivery (Audit Commission, 1993).

Moreover, appropriate and sensitive language use is an

integral part of this communication process and an

essential consideration for embracing cultural diversity

and fostering therapeutic relationships (NMC, 2004).

However, the importance of language appropriate

practice in healthcare is not as well established and

there is a paucity of research literature concerning the

significance of language in cross-cultural communica-

tion, particularly with minority language speakers.

Nevertheless, the recent enhanced status of many

minority languages, particularly across the European

community, has led to increasing demands for their use

within the public sector (European Charter for Regional

or Minority Languages, 1998). This is particularly

evident in health care, where, in situations of stress

and vulnerability, denying opportunities for patients to

communicate in their preferred language places them at

a personal disadvantage and may compromise their

health chances (Roberts, 1991).

In order to determine the most appropriate way of

integrating Welsh language services in healthcare provi-

sion in Wales, the Welsh Assembly Government

commissioned a 15 month national study in April 2003

to examine Welsh language awareness in healthcare and

identify the factors that enhance language choice for

service users. This paper reports on the NMHV data set

of the first phase of the study, which involved a

questionnaire survey of healthcare professionals across

Wales and examined the extent of their Welsh language

awareness. The findings are interpreted in light of

further research in the field of cross-cultural commu-

nication and the wider implications for nursing practice

are discussed.

2. Background

In line with increasing global diversity and the re-

vitalisation of many European minority languages,

multilingual societies are the norm across the world,

with as many as 66% of the world’s population speaking

two or more languages (Baker, 2001). According to the

2001 Census, over half a million people in Wales speak

Welsh, representing 21% of the total population

(National Assembly for Wales, 2003). Nevertheless,

although indigenous to Wales, Welsh is, by definition,

a minority language, in terms of relative power and

status (European Charter for Regional or Minority

Languages, 1998). This stems from its exclusion from

the official and public domain for over 4 centuries,

between the Act of Union (1536) that incorporated

Wales into England, and the establishment of the Welsh

Language Act (1967).

Diglossia is a common feature within minority

language communities, where different languages are

used for different societal functions (Baker, 2001). For

example, the majority language may be used at work, in

education and in the mass media, whilst the heritage,

minority language is often confined to the home and

social activities. Baker and Prys Jones (1998) argue that

this may affect the way in which the two languages are

perceived. For example, the majority language may be

considered to be superior and elegant; whilst the

minority language may be perceived to be inferior and

inadequate. Thomas (1994) and May (2000) claim that,

because of the marginalisation of minority languages,

their speakers share common experiences, including

discriminatory attitudes, linguistic oppression and lin-

guistic assimilation. Thus, comparing the use of the

Welsh language with other minority languages, particu-

larly in healthcare, enhances our understanding of

language appropriate practice and informs the process

of linguistic and cultural normalisation for policy and

practice.

Although most Welsh speakers in Wales also speak

English and are therefore bilingual, in situations of

stress and vulnerability many feel more comfortable and

ARTICLE IN PRESSG.W. Roberts et al. / International Journal of Nursing Studies 44 (2007) 1177–1186 1179

confident communicating in Welsh with healthcare

professionals (Roberts, 1991). Moreover, even those

who are fluent in English may temporarily lose their

command of English and revert completely to Welsh

when they are tired, ill, or under stress (Thomas, 1998).

However, despite these indications, a report from the

Welsh Consumer Council on Welsh in the Health

Service (Misell, 2000) suggests a significant shortfall in

the Welsh language awareness of practitioners in Wales

and a lack of commitment within healthcare organisa-

tions to plan for Welsh language provision. Such

deficiencies have been shown to compromise the quality

of care and treatment of Welsh speakers, particularly

amongst vulnerable client groups. Furthermore, they

contravene statutory requirements for bilingual provi-

sion in public services, as outlined in the Welsh

Language Act (1993). Thus, although an individualised

and holistic approach is central to the philosophy and

delivery of healthcare services (Welsh Assembly Gov-

ernment, 2001), there is evidence to suggest that

language barriers in healthcare may jeopardise the

health chances of Welsh speakers as minority language

service users in Wales. This is particularly true for

vulnerable groups, such as the elderly and people with

mental health problems; for whom denying language

choice can lead to misdiagnosis and inappropriate

treatment (Misell, 2000).

Arguably, the evidence to support such a claim is

largely anecdotal and limited to a modest number of

small-scale qualitative studies cited in the Welsh Con-

sumer Council report (Misell, 2000). However, wider

research examining the healthcare experiences of non-

indigenous minority language speakers in the UK

(Katbamna, 2000; Vydelingum, 2000; Gerrish, 2001);

USA (Timmins, 2002) and Australia (Cioffi, 2003)

confirms the detrimental effects of language barriers in

healthcare. Whilst the vast majority of this research also

constitutes small-scale qualitative studies, where caution

should be taken in the interpretation of findings, the

research provides valuable snapshots of the experiences

of minority language speakers in healthcare, together

with the challenges they encounter in clinical practice.

Recurrent themes emerging from this literature are the

significance of language and language choice to minority

speakers as a means of effective communication in

healthcare and the detrimental effects of language

barriers in jeopardising access to care and compromising

the quality of care and treatment.

Such barriers often arise out of a shortage of bilingual

practitioners (Timmins, 2002). Nevertheless, they may

also reflect a lack of language sensitivity amongst

healthcare professionals (Gerrish et al., 1996; Katbam-

na, 2000; O’Hagan, 2001), a concept defined by

Thompson (2003) as ‘‘ythe ability to recognise the

power of language and in what circumstances such

power can be abused or misused in reinforcing or

establishing patterns of inequality or discrimination.’’

(p. 116). The literature calls for an integrated approach

toward language appropriate healthcare practice, where

equal emphasis is placed on nurturing language sensi-

tivity as well as ensuring appropriate levels of language

proficiency amongst practitioners (Davies, 1999; Misell,

2000). This model reflects the wider concept of language

awareness, as described by James and Garrett (1991)

that incorporates several dimensions, including language

proficiency and confidence as well as attitude, motiva-

tion and actual usage. Nevertheless, the relationship

between these dimensions is poorly understood and the

determinants of language choice in healthcare are often

left unexplored.

Thus, in summary, although an individualised and

holistic approach is central to the philosophy and

delivery of healthcare, the evidence, albeit limited,

suggests a significant shortfall in the language awareness

of practitioners and a lack of commitment within

healthcare organisations to enhance communication

with minority language speakers. Language awareness

is therefore an important concept in healthcare, parti-

cularly in relation to cross-cultural communication, but

further research is required in order to examine the

dimensions of language awareness amongst healthcare

professionals and the way in which they facilitate

language choice for minority speakers.

3. Methodology

3.1. Aim and objectives

The aim of the study was to examine the factors that

influence Welsh language awareness amongst healthcare

professionals and the way in which they facilitate

language choice for patients and clients.

3.2. Design

The study was designed in two phases. The first phase

involved a large-scale questionnaire survey of a stratified

sample of healthcare professionals across Wales. The

second phase included face-to-face qualitative interviews

with a purposive sample of survey respondents (Irvine et

al., 2006).

3.3. Sample

In line with the specification of the commissioned

research, the aim of the sampling strategy was to include

a representative sample of practitioners from the public,

private and voluntary sectors across Wales and from a

range of healthcare professions. Adopting systematic

random sampling methods, a total of 1842 NMHV were

sought from the following healthcare organisations

ARTICLE IN PRESSG.W. Roberts et al. / International Journal of Nursing Studies 44 (2007) 1177–11861180

across Wales: all 15 NHS Trusts; all 21 Local Health

Boards which commission and deliver primary health-

care services; all 6 private hospitals; 10% of all private

nursing homes (n ¼ 39); and 8 voluntary organisations

that have a national remit and employ healthcare

professionals.

In view of the linguistic diversity of Wales, the

sampling of these participants incorporated stratifica-

tion according to three distinct language regions, as

determined by the 2001 Census Data (National Assem-

bly for Wales, 2003). Fig. 1 outlines a map of these

regions where Language Region 1 represents a percen-

tage population of 40–70% Welsh speakers; Language

Region 2 signifies a percentage population of 20–39%

Welsh speakers and Language Region 3 represents a

percentage population of 0–19% Welsh speakers.

3.4. Data collection

Data collection took place between July and Septem-

ber 2003. This involved the postal distribution of the

bilingual (Welsh/English) self-administered Welsh Lan-

guage Awareness in Healthcare Questionnaire (Roberts

et al., 2004), specifically developed to obtain information

from the target population.

Permission to undertake the study was granted from

the chief executive of each participating healthcare

organisation and, in line with the sampling frame

established, relevant human resource departments were

approached and asked to provide names and work

addresses of healthcare professionals in their employ.

Copies of the questionnaire were then distributed

directly to these healthcare professionals. Non-respon-

ders were sent follow-ups, according to a four-stage

process. Those organisations that declined to supply

names and work addresses distributed the question-

naires on behalf of the research team, according to the

strict sampling protocol provided. This amounted to

31% of the total questionnaires distributed.

3.5. Study instrument

The survey instrument was made up of seven discrete

sections exploring the participants’ demographic and

employment details; language environment; Welsh

language proficiency; use of the Welsh language; means

of facilitating language choice in healthcare; and

attitudes towards the Welsh language in healthcare.

The attitude measure contained 33 statements about

the Welsh language in healthcare. These items were

established from previous related research (Baker, 1992;

NOP Social and Political, 1995; Welsh Language Board,

2000) as well as from recurrent themes in the literature

(Misell, 2000; Davies, 1999), thereby ensuring the

content validity of the questionnaire (Parahoo, 1997).

The respondents were required to indicate on a five-

point Likert scale their level of agreement with each

statement, for example ‘The Welsh language is relevant

to healthcare in Wales’. The Likert scale ranged from

5 ¼ ‘strongly agree’ to 1 ¼ ‘strongly disagree’. A high

score indicated a positive attitude towards the Welsh

language in healthcare and a low score indicated a

negative attitude.

Multiple techniques were adopted in order to translate

the research instrument and ensure conceptual equiva-

lence between the English and Welsh versions. This

involved back-translation; the use of an expert panel

(McColl et al., 2001); and bilingual testing. Although

there is no standard guideline for instrument translation,

Maneesriwongul and Dixon (2004) argue that multiple

techniques show a substantial effort to assure validity of

the translation, allowing detection and correction of

discrepancies between source and target language

versions.

A pilot study was conducted with a group of

registered nurses (n ¼ 37) to assess item comprehension

and undertake item reliability analysis on the attitude

measure of the study instrument. An a reliability of .96

was found, indicating a highly satisfactory level of

attitude measure reliability (Howitt and Cramer, 1999).

3.6. Ethical considerations

Ethical approval for the study was obtained through

the Multi-Centre Research Ethics Committee for Wales

and Local Research Ethics Committees. Each question-

naire was coded in order to maintain confidentiality and

participants were assured that at no point would they or

their employing organisations be identifiable. Consent

was implied through the completion and return of the

research instrument. In the event of subjects declining to

participate in the study, they were asked to return the

blank questionnaire in order to reduce the level of

subsequent intrusion through unwanted reminders.

3.7. Data analysis

The descriptive and inferential statistics were com-

puted with the aid of the SPSS Windows Release 11.5

(2002) statistical package. Inferential statistics included

the application of ANOVA and correlation analysis.

4. Results

4.1. Response rate

Following the distribution of the questionnaires, 1042

(57%) were returned by the NMHV for analysis.

Amongst these respondents, health visitors (n ¼ 27)

demonstrated the highest response rate at 64%; followed

by nurses (n ¼ 975) at 55%; and midwives (n ¼ 40) at

ARTICLE IN PRESS

Fig. 1. Map showing the three distinct language regions of Wales according to the 2001 Census Data (National Assembly for Wales,

2003).

G.W. Roberts et al. / International Journal of Nursing Studies 44 (2007) 1177–1186 1181

49%. There was a 72% response rate from Language

Region 1; 62% from Language Region 2; and 54% from

Language Region 3. The ensuing discussion will proceed

to report on the NMHV data set.

4.2. Sample characteristics

The salient demographic and employment data are

presented in Table 1.

ARTICLE IN PRESSG.W. Roberts et al. / International Journal of Nursing Studies 44 (2007) 1177–11861182

The majority of respondents (89%) were female; born

in Wales (64%); with an average age of between 35 and

44 years. The great majority of the respondents (76%)

were employed within the public sector, with 70%

engaged in hospital services and 65% derived from

Language Region 3 (n ¼ 673). Of all the professional

groups represented within the survey, NMHV had lived

Table 1

Salient sample characteristics of nurses, midwives and health

visitors

Characteristics n %

Gender

Male 96 9

Female 931 89

Not noted 15 1

Mean age range (years) 35–44

Country of birth

Wales 667 64

Other part of UK 280 27

Outside the UK 68 7

Not noted 27 3

Number of years lived in Wales 11–20 years on average

Healthcare sector

Public sector 792 76

Private sector 48 5

Voluntary sector 15 1

Not noted 187 18

Healthcare settinga

Primary/community service 272 26

Hospital service 732 70

Rehabilitation service 48 5

Language Region

Language Region 1 163 16

Language Region 2 206 20

Language Region 3 673 65

Welsh language proficiency

No proficiency 475 46

A little proficiency 385 37

Fairly proficient 61 6

Very proficient 121 12

Welsh language attitudes

Negative attitudes 127 12

Neutral attitudes 444 43

Positive attitudes 471 45

Welsh language use

Use Welsh with patients 323 32

Language Region 1 112 70

Language Region 2 81 41

Language Region 3 130 20

aTotal is n ¼ 1052 for healthcare settings (n ¼ 10 more than

the number in the Nursing group as a whole (n ¼ 1042). Some

may have a dual role.

in Wales for a significantly longer period than their

colleagues from other healthcare professions (po:001).Indeed, the great majority (80%) reported to have lived

in Wales for over 21 years.

4.3. Welsh language proficiency in healthcare

Table 1 outlines the levels of Welsh language

proficiency amongst the NMHV. Over half of the

respondents (55%) reported that they could speak at

least a little Welsh, which was defined in the ques-

tionnaire as more than none at all, but less than a little.

However, only 18% were fluent Welsh speakers, who

reported that they spoke Welsh either very well or fairly

well.

The distribution of Welsh language proficiency

amongst NMHV across the three language regions is

outlined in Table 2.

This shows that, in line with the wider distribution of

Welsh speakers amongst the general population, as

identified in the 2001 Census (National Assembly for

Wales, 2003), levels of Welsh language proficiency

amongst NMHV increased significantly from 10% in

Language Region 3 who reported that they could speak

at least a little Welsh to 19% in Region 2 to 46% in

Region 1. In other words, there is a strong correlation

between the Welsh language proficiency of NMHV and

the language region in which they work (r ¼ �:38,po:001).

4.4. Welsh language attitudes in healthcare

Individual language attitude scores of the NMHV

were determined for each respondent by calculating the

mean score across the attitude statements. This yielded a

range of attitude scores with a value of between one and

five, with one representing the most negative attitudes

and five the most positive attitudes towards the Welsh

language in healthcare. For the purpose of analysis,

these scores were grouped according to three overall

attitude categories, as follows:

�

Tab

We

visi

We

spe

pro

No

A l

Fai

Ver

Negative attitude (mean scores between 1.00 and

2.60)

le 2

lsh-speaking proficiency of nurses, midwives and health

tors by language region

lsh-

aking

ficiency

Region 1 (%) Region 2 (%) Region 3 (%)

t at all 16 (n ¼ 26) 38 (n ¼ 78) 55 (n ¼ 371)

ittle 38 (n ¼ 62) 43 (n ¼ 89) 35 (n ¼ 234)

rly well 9 (n ¼ 15) 10 (n ¼ 20) 4 (n ¼ 26)

y well 37 (n ¼ 60) 9 (n ¼ 19) 6 (n ¼ 42)

ARTICLE IN PRESSG.W. Roberts et al. / International Journal of Nursing Studies 44 (2007) 1177–1186 1183

�

Tab

We

Lan

Ne

Ne

Pos

Neutral attitude (mean scores between 2.61 and 3.39)

�

27%

22%

25%

15% 14% 14%

0%

5%

10%

15%

20%

25%

30%

Context of language use

% u

sing

Wel

sh w

ith p

atie

nts

Providingreassurance

Gaining

Giving SimpleAdvice

Providingcounselling/therapy

Giving complexinformation

Obtaining informedconsentInformation

Fig. 2. Context of Welsh language use of nurses, midwives and

health visitors.

Positive attitude (mean scores between 3.40 and 5.00)

The findings show that 45% of the NMHV demon-

strated positive attitudes towards the Welsh language in

healthcare, whilst only 12% demonstrated negative

language attitudes. Nevertheless, 43% revealed neutral

language attitudes.

Table 3 outlines the language attitudes of the NMHV

according to their language region.

A one-way ANOVA was conducted to investigate

whether mean attitudes varied across the three language

regions. It was found that there was a significant

difference between the regions, F(2,1039) ¼ 12.87,

po:001. Bonferroni post hoc tests showed that the

participants from Region 1 had more positive attitudes

towards the Welsh language than those in Region 3, but

there was no difference between Regions 1 and 2. Those

in Region 2 were also more positive than those in

Region 3.

In view of the strong correlation between the Welsh

language proficiency of NMHV and their language

region, it is hardly surprising that their language

attitudes correlate strongly with their levels of Welsh

language proficiency (r ¼ �:19, po:001).

4.5. Welsh language use in healthcare

Only those participants who reported to speak at least

a little Welsh were invited to describe their Welsh

language use in healthcare and this is reported in

Table 1.

The patterns of Welsh language use across the regions

closely reflect the distribution of Welsh language

proficiency and attitudes amongst the respondents, as

described earlier. For example, in Language Region 3,

where NMHV demonstrated the lowest levels of Welsh

language proficiency and the least positive attitudes,

only 20% use Welsh with Welsh-speaking patients and

clients, whilst this figure rises significantly to 41% in

Region 2 and then rises again to 70% in Region 1. A

one-way ANOVA showed that the differences between

the regions were very significant, F(2,1016) ¼ 92.13,

po:001.Whilst the results indicate that the extent of Welsh

language use in healthcare amongst nurses, midwives

and health visitor is determined by their levels of Welsh

le 3

lsh language attitudes of nurses, midwives and health visitors by l

guage attitudes Region 1 (%) Region

gative 7 (n ¼ 12) 9 (n ¼

utral 35 (n ¼ 57) 38 (n ¼

itive 58 (n ¼ 94) 53 (n ¼

language proficiency and attitudes, it is also dependant

on the context of care. Fig. 2 demonstrates that NMHV

are significantly more likely to use Welsh in informal

patient interactions, such as providing reassurance,

rather than formal encounters, such as giving complex

information or obtaining consent (po:01).

5. Discussion

This large-scale survey provides a unique overview of

Welsh language awareness amongst NMHV across

Wales and highlights the effects of their language

proficiency and attitudes on minority language use in

bilingual healthcare settings. In light of the increasing

global emphasis on language appropriate practice in

healthcare (Generalitat de Catalunya, 1998; United

States Department of Health and Human Services,

Office of Minority Health, 2000; Welsh Assembly

Government, 2003) these findings have particular

significance for enhancing cross-cultural communication

across other bilingual and multilingual healthcare

settings.

Despite limited levels of Welsh language proficiency

amongst NMHV across Wales, there are encouraging

signs to suggest that even those with modest proficiency

endeavour to use the language with patients and clients,

particularly within an informal context. This pattern is

anguage region

2 (%) Region 3 (%) Total (%)

18) 14 (n ¼ 97) 12 (n ¼ 127)

78) 46 (n ¼ 309) 43 (n ¼ 444)

110) 40 (n ¼ 267) 45 (n ¼ 471)

ARTICLE IN PRESSG.W. Roberts et al. / International Journal of Nursing Studies 44 (2007) 1177–11861184

not unique to Wales, but also reported in studies

undertaken in Sydney, Australia (Johnson et al., 1998,

1999). These exploratory reviews demonstrated that the

minority language skills of most bilingual healthcare

staff were restricted to the social domain, thus limiting

their interactions with minority speakers to the level of

social engagement, such as communicating social

pleasantries. In contrast, only a small number of

practitioners had minority language skills that enabled

them to engage in complex information exchanges with

patients, such as giving medico-legal information.

Clearly, even a limited utterance, for example, a simple

greeting, can help establish a rapport and therapeutic

bond between the practitioner and patient (Misell, 2000;

Bradby, 2001; Cioffi, 2003). However, higher level

interactions require more advanced language skills and

the confidence to apply them across practice domains.

Our survey findings suggest that there is encouraging

potential for enhancing cross-cultural communication in

healthcare across language domains by extending the

language proficiency of NMHV and building on existing

skills and confidence through appropriate training

initiatives.

Pugh (1996) argues that the increasing dominance of

English as a global language has led to an ideology

amongst many of its speakers that reflects positive

attitudes towards English and negative ones towards

most other languages. Although this was identified in

the literature review (Bowler, 1993; Katbamna, 2000;

O’Hagan, 2001), it is not upheld in our survey since,

given the linguistic profile of the participants, the

findings give rise to more positive language attitudes

than expected. Although social desirability effects may

partly account for this outcome (Parahoo, 1997), it is

also supported by an Australian study where Cioffi

(2003) showed that nurses were empathic, respectful and

willing to make an effort to reduce the marginalisation

of linguistically diverse patients. These are encouraging

findings, since in the absence of minority language

speakers amongst the healthcare team, facilitating

language choice for patients often hinges on the

language sensitivity of those from the dominant

language group (Misell, 2000; Timmins, 2002).

In view of the strong correlation between language

proficiency and language attitudes and the unexpectedly

low levels of negative attitudes reported amongst the

respondents, it appears that other factors may be

involved in shaping language attitudes in healthcare.

These are explored during the second phase of the study

(Irvine et al., 2006).

In light of the significant levels of neutral language

attitudes demonstrated by NMHV in this survey, there

is encouraging potential to establish language awareness

training initiatives, as recommended by the United

States Department of Health and Human Services

(2000) and Misell (2000), as a means of facilitating

cross-cultural communication in healthcare. Indeed,

according to Papadopoulos et al.’s (1998) model for

developing culturally competent health practitioners,

this may require only a modest shift along the cultural

competence continuum, which could readily be achieved

through training initiatives.

Given the strong association between language

attitudes and proficiency levels, as identified in this

survey and other household surveys (NOP Social and

Political, 1995; Welsh Language Board, 2000), language

awareness training initiatives may also encourage

practitioners to become more receptive towards lan-

guage learning and thus, through enhanced language

proficiency, shift their ability to use Welsh in the formal

as well as the social domain.

Of all the healthcare professionals in the study, the

data revealed that NMHV reported the longest residency

in Wales and were more likely to be recruited locally.

They are thus more likely to reflect the cultural back-

ground of their patients and clients, thereby strengthening

their potential role as the patient’s advocate. Moreover,

Mallik (1997) suggests that nurses are ideal ‘natural

mediators’ in healthcare, in view of their position and role

within the multi-disciplinary team. Their role as ‘com-

munication brokers’ is further supported by Bourhis

et al., (1989) who described nurses as key mediators in

healthcare, using ‘everyday language’ with patients and

‘medical language’ with doctors. It is reasonable, there-

fore, to suggest that NMHV should be supported to

maintain their leading role in establishing language

awareness within the delivery of healthcare.

6. Study limitations

Interpretation of the study findings should take into

consideration the following limitations. Firstly, indirect

mailing through participating organisations may have

introduced a sample bias (Coolican, 1994). In an

attempt to eliminate this effect, organisations were

encouraged to adhere to the strict sampling protocol.

Secondly, under-reporting of minority language profi-

ciency is a common feature amongst minority speakers

since, as a result of conventions of language use,

speakers often lack confidence in using their heritage

language in the formal domain (Baker, 2001). Thus

actual levels of Welsh language proficiency amongst the

survey respondents may have been higher than reported

and this, along with social desirability effects, may

account for the unexpectedly low levels of negative

language attitudes found.

7. Conclusions

The literature suggests that there are significant

shortfalls in relation to language appropriate practice

ARTICLE IN PRESSG.W. Roberts et al. / International Journal of Nursing Studies 44 (2007) 1177–1186 1185

that compromise the health chances of minority

language speakers across a range of multilingual

communities. This survey confirms that cross-cultural

communication is enhanced by nurses’ language atti-

tudes and proficiency levels. Furthermore, it demon-

strates that there is encouraging potential to establish

training initiatives in order to enhance language aware-

ness and develop language proficiency for practice. This

should facilitate language choice for patients in cross-

cultural encounters and enhance the quality of care

delivery across language communities.

Acknowledgements

This study was commissioned by the Welsh Assembly

Government. We also wish to acknowledge the con-

tribution of the healthcare professionals in Wales who

generously gave their time to participate in the study.

References

Audit Commission, 1993. What Seems to be the Matter?:

Communication Between Hospitals and Patients. H.M.S.O.,

London.

Baker, C., 1992. Attitudes and Language. Multilingual Matters,

Clevedon.

Baker, C., 2001. Foundations of Bilingual Education and

Bilingualism, third ed. Multilingual Matters, Clevedon.

Baker, C., Prys Jones, S. (Eds.), 1998. Encyclopaedia of

Bilingualism and Bilingual Education. Multilingual Mat-

ters, Clevedon.

Bourhis, R., Roth, S., MacQueen, G., 1989. Communication in

the hospital setting: a survey of medical and everyday

language use amongst patients, nurses and doctors. Social

Science and Medicine 28, 339–346.

Bowler, I., 1993. Stereotypes of women of Asian descent in

midwifery: some evidence. Midwifery 9, 7–16.

Bradby, H., 2001. Communication, interpretation and transla-

tion. In: Culley, L., Dyson, S. (Eds.), Ethnicity and Nursing

Practice. Palgrave, Hampshire, pp. 129–148.

Cioffi, R., 2003. Communicating with culturally and linguisti-

cally diverse patients in an acute care setting: nurses’

experiences. International Journal of Nursing Studies 40 (3),

299–306.

Coolican, H., 1994. Research Methods and Statistics in

Psychology, second ed. Hodder & Stoughton, London.

Davies, E., 1999. The Language of a Caring Service. Welsh

Language Board, Cardiff.

European Charter for Regional or Minority Languages, 1998.

European Commission, Brussels.

Generalitat de Catalunya, 1998. Act No 1, of 7th January 1998

on Linguistic Policy. Generalitat de Catalunya, Barcelona.

Gerrish, K., 2001. The nature and effect of communication

difficulties arising from interactions between district nurses

and South Asian patients and their carers. Journal of

Advanced Nursing 33 (5), 566–574.

Gerrish, K., Husband, C., Mackenzie, J., 1996. Nursing for a

Multi-ethnic Society. Open University Press, Buckingham-

shire.

Howitt, D., Cramer, D., 1999. A Guide to Computing Statistics

with SPSS Release 8 for Windows. Prentice-Hall, London.

Irvine, F.E., Roberts, G.W., Jones, P., Spencer, L.H., Baker,

C.R., Williams, C., 2006. Communicative sensitivity in the

bilingual healthcare setting: a qualitative study of language

awareness. Journal of Advanced Nursing 53 (4), 1–13.

James, C., Garrett, P. (Eds.), 1991. Language Awareness in the

Classroom. Longman, London.

Johnson, M., Noble, C., Matthews, C., Aguilar, N., 1998.

Towards culturally competent healthcare: language use of

bilingual staff. Australian Health Review 21 (3), 49–66.

Johnson, M., Noble, C., Matthews, C., Aguilar, N., 1999.

Bilingual communicators within the healthcare setting.

Qualitative Health Research 9 (3), 329–343.

Katbamna, S., 2000. Race and Childbirth. Open University

Press, Buckinghamshire.

Mallik, M., 1997. Advocacy in nursing: a review of the

literature. Journal of Advanced Nursing 25, 130–138.

Maneesriwongul, W., Dixon, J., 2004. Instrument translation

process: a method review. Journal of Advanced Nursing 48

(2), 175–186.

May, S., 2000. Uncommon languages: the challenges and

possibilities of minority language rights. Journal of Multi-

lingual and Multicultural Development 21, 366–385.

McColl, E., Jacoby, A., Thomas, L., Soutter, J., Bamford, C.,

Steen, N., Thomas, R., Harvey, E., Garratt, A., Bond, J.,

2001. Design and use of questionnaires: a review of best

practice applicable to surveys of health service staff and

patients. Health Technology Assessment 5, 31.

Misell, A., 2000. Welsh in the Health Service: The Scope,

Nature and Adequacy of Welsh Language Provision in the

National Health Service in Wales. Welsh Consumer

Council, Cardiff.

National Assembly for Wales, 2003. National Statistics.

National Assembly for Wales, Cardiff.

Nursing and Midwifery Council, 2004. Code of Professional

Conduct: Standards for Conducts, Performance and Ethics.

Nursing and Midwifery Council, London.

NOP Social and Political, 1995. Public Attitudes to the Welsh

Language. NOP Social and Political, London.

O’Hagan, K., 2001. Cultural Competence in the Caring

Professions. Kingsley Publishers, London.

Papadopoulos, I., Tilki, M., Taylor, G., 1998. Transcultural

Care: A Guide for Health Care Professionals. Quay Books,

Wiltshire.

Parahoo, K., 1997. Nursing Research: Principles, Processes and

Issues. Macmillan Press Limited, Basingstoke.

Pugh, R., 1996. Effective Language in Health and Social Work.

Chapman & Hall, London.

Roberts, G., 1991. The use of the Welsh language in nurse-patient

communication within a bilingual health care setting. Unpub-

lished MN Thesis. University of Wales, Cardiff.

Roberts, G., Irvine, F., Jones, P., Spencer, L., Baker, C.,

Williams, C., 2004. Report of a Study of Welsh Language

Awareness in Healthcare Provision in Wales. Welsh

Assembly Government, Cardiff.

SPSS for Windows, Release 11.5, 2002. SPSS Screen Images.

SPSS Inc., Chertsey, Surrey.

ARTICLE IN PRESSG.W. Roberts et al. / International Journal of Nursing Studies 44 (2007) 1177–11861186

Thomas, N., 1994. Welsh-speakers as a territorial linguistic

minority in the European Union. In: Williams, R., Williams,

H., Davies, E. (Eds.), Social Work and the Welsh Language.

CCETSW Wales, Cardiff, pp. 155–171.

Thomas, G., 1998. The experiences of welsh speaking women in

a bilingual maternity service. Unpublished M.Sc. Thesis,

University of Wales, Cardiff.

Thompson, N., 2003. Communication and Language: A

Handbook of Theory and Practice. Palgrave Macmillan,

Basingstoke, UK.

Timmins, C., 2002. The impact of language barriers on the

health care of Latinos in the US: a review of the literature

and guidelines for practice. Journal of Midwifery and

Women’s Health 47 (3), 80–96.

United States Department of Health and Human Services,

Office of Minority Health, 2000. National Standards on

Culturally and Linguistically Appropriate Services (CLAS)

in Health Care. United States Government Printing

Office.

Vydelingum, V., 2000. South Asian patients’ lived experience of

acute care in an English hospital: a phenomenological study.

Journal of Advanced Nursing 32 (1), 100–107.

Welsh Assembly Government, 2001. Improving Health in

Wales: A Plan for the NHS with its Partners. Welsh

Assembly Government, Cardiff.

Welsh Assembly Government, 2003. Iaith Pawb: A National

Plan for a Bilingual Wales. Welsh Assembly Government,

Cardiff.

Welsh Language Act, 1967. HMSO, London.

Welsh Language Act, 1993. HMSO, London.

Welsh Language Board, 2000. State of the Welsh Language

2000. Welsh Language Board, Cardiff.