Communication is imperative for high-quality, safe healthcare (Levinson et al, 2010; Vermeir et al, 2015; Foronda et al, 2016). Communication between patients, health professionals and local communities has been central to healthcare improvement strategies such as the 6Cs (Department of Health, 2012), Better Births (National Maternity Review, 2016) and the Five Year Forward View (NHS England et al, 2014). Furthermore, poor communication has been linked to compromised patient safety, negative patient experiences and inefficient physician worktime (Vermeir et al, 2015) and in maternity services, has been shown to make women in labour feel less in control and more negative about their experiences (World Health Organization (WHO), 2016; National Institute for Health and Care Excellence (NICE), 2017). To improve and advance communication, NHS England created an accessible information and communication policy (NHS England Patient and Public Participation and Insight Group, 2016) that outlines the importance of accessible, inclusive information and communication for all, supporting the NHS Constitution's key principle that the patient will be at the heart of everything that it does (Department of Health, 2015). A central method of communication is the use of language. Language is both used and experienced by all health professionals and those in their care, and so the use of medical jargon, positively or negatively skewed phrasing and for those for whom English is not a first language should all be considered. This article will explore each of these elements of language within maternity services and their context within patient safety and experience.
Medical jargon
Medical jargon is a term to describe the medical language or abbreviations used as shorthand by health professionals (Subramaniam et al, 2017). In a team environment it can appear to be efficient shorthand; however, inappropriate use with patients has been found to negatively influence empowerment, autonomy, psychological wellbeing, satisfaction and compliance (Fields et al, 2008; Roter et al, 2009; Hong et al, 2010; Dahm, 2015; Subramaniam et al, 2017). Using language that individuals cannot understand leads to a more traditional paternalistic model of care in which the practitioner makes decisions for the patient (Sartorius, 1983). This model of care is contrary to the Nursing and Midwifery Council (NMC) Code in which informed, shared decision-making is promoted as best practice (NMC, 2018).
By taking away patient autonomy and understanding, excessive use of medical jargon conflicts three elements of the medical ethics model that underpin healthcare practice in the UK: beneficence (‘doing for the good’), non-maleficence (‘doing no harm’) and fairness (Beauchamp and Childress, 2001). Research examining birth footage highlighted a lack of information and the use of medical jargon before interventions or procedures, with health professionals leading choices rather than women (De Benedictis et al, 2019). This demonstrates a lack of beneficence and non-maleficence, as the use of efficient, understandable language allows informed consent and the involvement of women in decision-making. Informed consent is known to decrease anxiety, further understanding around individuals' own health and increase patient satisfaction (Goldberger et al, 2011), increasing fairness. The use of medical jargon in maternity services therefore reintroduces paternalistic care and compromises medical ethics by reducing patient autonomy, informed consent and involvement in their own care.
Emotive language
The emotive impact of language choices in maternity care is also known to influence outcomes. The use of words such as ‘failure’, ‘tear’ and ‘inflamed’ are used regularly in discussions of women's care, and have been found to negatively affect psychological wellbeing and pain tolerance (Vranceanu et al, 2012). Practitioners' use of positive language has been found to have patient benefits, especially regarding pain (Howick et al, 2018). As a result, traditional hypnobirthing practices, which emphasise the importance of using alternative positive language such as ‘waves’ or ‘surges’ rather than ‘contractions’ or ‘pains’, have become increasingly popular in the UK (Graves, 2017). This supports the self-affirmation theory, the belief that individuals have a fundamental motivation to maintain their self-integrity and preparedness for every situation (Steele, 1988). This theory implies that positive language from health professionals reaffirms to women their underlying belief that they can cope with childbirth, encouraging their core motivation to succeed.
Conversely, self-fulfilling prophecy theory would argue that the outcome of a person's experience is skewed by their expectation, thus if a woman expects a negative, painful birth, that is what she will experience, despite other factors such as midwifery input or positive language (Merton, 1948). However, research into reducing fear of birth has shown that midwife-led support can reduce anxiety towards labour, helping women to feel more confident and prepared for birth (Serçekus and Baskale, 2016; Andaroon et al, 2017). This conflicts the self-fulfilling prophecy theory and demonstrates the influence of midwives, which results in a more positive mindset among women in their care.
English as a second language
Another element of language in healthcare is that when patients do not have English as a first language. It has been found that 40% of women from ethnic minorities experience problems with communication, discrimination and poorer care during their maternity journey (Attanasio and Kozhimannil, 2015). Women experiencing maternity care who do not speak English have been found to feel defenceless, to have a lack of understanding of their care options, to experience reduced informed consent and to have more negative experiences overall (Binder et al, 2012; Small et al, 2014; Yelland et al, 2015). However, it has been found that 12.7% of NHS staff, including 6.8% of all nurses and health visitors, declare themselves as not of British origin (Baker, 2018). This could signify that some patients interact with healthcare providers in other languages, which would minimise some miscommunications. In spite of this, research into this is limited, possibly because of the small probability of physicians and clients speaking the same foreign language.
To mitigate the effects of language barriers, NICE (2010) guidelines recommend always using a language-appropriate interpreter to translate during a woman's interaction with healthcare providers throughout her care. Studies have shown that use of competent interpreters empowers women to feel listened to and more involved in their care (Lyberg et al, 2012; Puthussery et al, 2015). However, in the 2015 MBRRACE report, it was highlighted that absence or misuse of interpreters had contributed to some of the gaps in women's care and, in cases, to maternal deaths (Knight et al, 2015). Further UK studies suggest that interpreters are not always present at every appointment, appropriately skilled or reliable, and that health professionals are not trained in communicating through interpreters, meaning that often the woman's family members are regularly used to translate (Meddings and Haith-Cooper, 2008; Stapleton et al, 2013; Mone et al, 2015). The Standards for Pre-Registration Midwifery Education (NMC, 2009) stipulate that a woman who does not speak English should expect her midwife to be able to share information with her confidently. However, it does not require any specific formal training in communicating through an interpreter, which is known to improve practitioner effectiveness and patient experience (Pechak et al, 2018; Omoruyi et al, 2018). With interpreters costing the NHS £48 for an hour, and then between £16-32 for each further hour (UK Visas and Immigration, 2015), it could be argued that interpreters cost the NHS a considerable amount of money. Some midwives feel that this is cost is too much for the NHS (Tobin and Murphy-Lawless, 2014) although this may be linked to their experiences of poor quality, inappropriately skilled interpreters or because they themselves feel ill-equipped to use interpreters.
Conclusion
The influence of language in maternity services is multifaceted. With communication central to high quality care, language can significantly affect both patient safety and experiences. The use of medical jargon disempowers patients and detracts from their involvement in their own care decisions by reducing understanding. Further more, emotive language can have either a positive or negative effect on women during their maternity experience. However, as every individual is different, it is difficult to identify the exact effect of this as some women are more influenced by health professionals' input than others. Language disparities in the UK mean that non-English speakers are known to have more negative experiences than those for whom English is a first language. The use of interpreters can mitigate these to an extent; however, there are concerns about the quality and availability of appropriate interpreters and the lack of training for health professionals in communicating through translators. Overall, language has a significant role to play in a woman's maternity journey and health professionals need to be conscious of this to enable effective communication.
Key points
- The use of medical jargon is detrimental to maternity service user's experiences by detracting from individuals' autonomy and ability to achieve informed consent
- Emotive language such as ‘failure’ or ‘tear’ negatively skews women's mindsets whereas more positive words from midwives can improve self-belief and reduce pain
- Those without English as a first language experience poorer birth experiences, feeling more helpless and a lack of understanding
- Effective use of translators can improve care, however their use are limited by misuse and healthcare professional's skill
CPD reflective questions
- How is your use of language affecting people using maternity services in your day to day work?
- What changes could you make to improve your communication, focusing on simplifying medical jargon and promoting positivity in your workplace?
- How could your Trust or workplace enable more effective use of interpreters?