Article

Nordic Journal of Nursing Research

2021, Vol. 41(1) 42–53
! The Author(s) 2019
The significance of communication and care Article reuse guidelines:
sagepub.com/journals-permissions
in one’s mother tongue: Patients’ views DOI: 10.1177/2057158519877794
journals.sagepub.com/home/njn

Jessica Hemberg and Emelie Sved

Abstract
Language barriers in the healthcare sector, for example as a result of failure to use a patient’s mother tongue, can lead to
misunderstandings and/or care errors, especially when circumstances require that nursing staff or patients speak a language
other than their own mother tongue. The aim of this study was to explore the importance of patients receiving care in their
mother tongue. A hermeneutic approach was used and the method was inspired by content analysis. The data material was
collected through semi-structured interviews with nine adult patients. One main theme and four subthemes were seen. The
main theme was that care in a patient’s mother tongue can enhance quality of care. To reduce suffering in care caused by
language barriers, nurses’ language skills should be supported and encouraged. Further research should focus on nurses’
perspectives on the significance of minority-language patients using their mother tongue in a nursing context.

Keywords
communication, content analysis, hermeneutics, intercultural, language policy, nurse–patient relationships, quality of care

Accepted: 2 September 2019

relation to intercultural communication that, ‘the deter-

Introduction
Clear communication in healthcare is important for
patients,1 and nurse–patient communication is crucial to
maintaining the quality of care.2–5 When nursing staff and
patients do not speak the same language, serious commu-
nication problems may arise,6–8 which can also jeopardize
patient safety and patients’ experiences of good care.9–16
Background
Human beings create their perceived reality and self
through language.17 In caring situations, because of its
important emotional dimension, language is much more
than a tool for communication.18 It is easier to express
feelings and emotions in one’s mother tongue than in
any other language, because it is considered the ‘language
of emotion’.18 Language barriers may lead to impaired
caring relationships.19 Language and culture are inter-
twined, and because of this there is a need to discuss the
concepts in relation to one another. Piller20 found that
culture is a multifaceted concept that can be defined in
many different ways, e.g. the essentialist assumption that
people have or belong to a culture. Piller20 also found,
when analysing culture-related texts, that a cultural unit
formed the scope of each underlying understanding of cul-
ture investigated in her work, and thus concluded that the
nation can be considered a basic unit of culture. Piller even
saw that, ‘intercultural communication is one domain
where ‘‘culture’’ as concerned with the specific – and the
different – ways of life of different national and ethnic
groups is constructed’.20(p.16) Arasaratnam found in
mining factor is when cultural differences between the rele-
vant individuals affect the communication exchange in
ways which would have been insignificant had those differ-
ences not existed’.21(p.136) Arasaratnam21 also maintained
that people who do not share similar cultural values and
beliefs do not communicate within the context of shared
assumptions, and not sharing such a context can easily lead
to misunderstandings. According to Piller,22 multilingual-
ism, a related concept, can be considered an umbrella term
that encompasses an extensive range of linguistic contexts
and practices. In today’s multi-ethnic society, it is essential
to be able to communicate with people from different
countries, and consequently intercultural communication
is highly important.23
Information asymmetries arise in healthcare when one
party has skills and knowledge that the other party does
not have but needs,24 and Alpers25 maintained that all
healthcare staff–patient relationships are more or less
asymmetric. Even greater asymmetry is seen when there
are linguistic and cultural differences between healthcare
staff and patients, e.g. patients’ dissimilar understanding of
illness anthologies may make them even more vulnerable in
care.25 Such differences can make the building of a trusting
Faculty of Education and Welfare Studies, Åbo Akademi University, Finland
Corresponding author:
Jessica Hemberg, Åbo Akademi University, Faculty of Education and Welfare
Studies, Department of Caring Sciences, PB 311, 65101 Vaasa, Finland.
Email: jessica.hemberg@abo.fi
Hemberg and Sved
and positive healthcare staff–patient relationship difficult,
especially with ethnic minority patients.25
The capacity to exhibit cultural sensitivity is also
important for nurses,26,27 because such sensitivity enables
nurses’ understanding of patients’ various needs.28 A cul-
turally competent nurse strengthens the caring relationship
and patients’ positive experiences of care.29 For nurses and
patients with different cultural backgrounds, intercultural
caring is the core of caring work.30 Nurses’ experiences of
minority language issues, or if they belong to a minority
themselves, can impact how they treat patients from cul-
tural minorities and how they understand language or
communication difficulties.28 Cultural problems that can
emerge when nurses and patients do not have a shared
language include confusion, misunderstandings, prejudice,
negative attitudes, anxiety or misconstrued care instruc-
tions.31 Likewise, the language used for communication
may be perceived as being terse or rude or an impasse
may arise in the caring situation.18 Language barriers
between nurses and patients in care can also result in dan-
gerous situations and risks related to medication, pain
treatment, diagnosis, the communication of risks and/or
emergency situations.32 To support healthcare staff, it is
important that language barriers be adequately detected
and reported.32
Professional interpreters can help eliminate the risks
that can arise as a result of language barriers and can
help maintain the quality of care.29,33–35 Professional inter-
preters can be used to overcome linguistic, cultural and
knowledge barriers, but they are not always available in
healthcare settings.28,36 According to Roberts et al.,37 in
bilingual countries nurses who belong to the linguistic
majority population and have the country’s majority lan-
guage as their mother tongue are often willing and capable
of speaking the country’s minority language, provided they
have mastered this language, when talking about everyday
matters with patients who speak the minority language.
Still, Roberts et al. found that nurses prefer to use their
mother tongue when providing patients with important
information about, e.g. medication. Other researchers
have found that when healthcare staff speak to a minority
language patient they use a ‘basic’ or simplified version of
the majority language, which can lead to nurse–patient
misunderstandings.28 Bilingual patients often switch
between languages, as they are unable to express them-
selves equally in both languages, and also tend to revert
to their mother tongue when expressing strong emotions.17
Researchers have found that nurses’ positive attitudes
toward a minority language are important, because this
indicates that the nurses use the minority language which
in turn encourages minority-language patients to use their
mother tongue.37 While everyday discussions can help
build good nurse–patient relationships, when caring for
minority-language patients it is also beneficial that health-
care staff provide instructions in the minority language,
although this requires good proficiency in the language.37
Still, nurses’ positive linguistic attitudes tend to change
when they experience problems in practice, and conse-
quently practical courses on how to use professional
43
interpreters in healthcare would be useful.37 Jones et al.38
found that healthcare staff underutilize professional inter-
preters, even though researchers and policy-makers alike
recommend using such services. Practical courses39 or edu-
cation and training40 have been found to possibly improve
healthcare staff’s negative attitudes toward professional
interpreter services.
If the patient’s right to a professional interpreter has not
been taken into account, it can lead to serious conse-
quences32,40 and thereby affect the quality of care. Using
alternative means to communicate when professional inter-
preter services are not available can lead to misunderstand-
ings, misinterpretations or even inferior care. Language
brokers, i.e. non-professional, informal interpreters such
as a patient’s next of kin, are sometimes used.40 Yet
researchers have found that language brokers often are
dominant and excluding in their roles and often ‘speak
as themselves’ rather than accurately transferring
information.41,42
Aims
The aim was to explore the importance of patients receiv-
ing care in their mother tongue.
Theoretical perspective
A language policy perspective was assumed in this study.
According to Thomason and Kaufman, ‘languages are a
product of, and a vehicle for, communication among peo-
ple’.41(p.4) The Office of the United Nations High
Commissioner for Human Rights (OHCHR)42 stated
that language is key to social inclusion and can be seen
as the centre of human activity, self-expression, identity
and culture and must consequently be protected and
respected.42 Henderson et al.43 found that because commu-
nication entails context and interaction, language skills are
complex and socially constructed.
There are an estimated 5000–6000 languages in the
world, yet according to Piller only 15 languages account
for the overwhelming majority of Wikipedia entries: of
these there are 2.5 times more entries for the first-most
frequently used language, English (4,948,736), than for
the second-most frequently used language, Swedish
(1,974,655).22 In the European Union (EU), language
diversity and aspects of societal and individual multilin-
gualism have been given rather high consideration,44 and
minority languages are seen as a valuable part of the cul-
tural and linguistic heritage of the EU.45 The European
Charter for Regional or Minority Languages (ECRML)
was drawn up in 199246 with the intention to preserve lin-
guistic diversity throughout the EU and call attention to
language planning concerns at the highest level,45 even
though its underlying purpose is nevertheless considered
to be cultural.47 In the ECRML it is stated that, ‘the pro-
tection of the historical regional or minority languages of
Europe, some of which are in danger of eventual extinc-
tion, contributes to the maintenance and development of
Europe’s cultural wealth and traditions’.46(p.15) Also, ‘the
44
charter sets out to protect and promote regional or minor-
ity languages, not linguistic minorities’.46(p.16) In 2003 the
European Commission launched the Action Plan 2004–
2006, with the purpose of promoting language learning
and linguistic diversity and this, along with other initia-
tives, has been considered one of the most important pro-
cesses in the EU’s history and a turning point for the EU’s
language policy.45
The promotion and protection of the identities of linguis-
tic minorities is perceived as being central to the rights of
minorities, and as such is also important with regard to a
person’s private life, identity and dignity.45 According to the
OHCHR, ‘‘‘language rights’’ and ‘‘linguistic human rights’’
are human rights which have an incidence on language pref-
erences of or use by state authorities, individuals and other
entities’.42(p.4) Arzoz,47 referring to Foucher, found that the
idea underlying the recognition of language rights was to
protect specific linguistic minorities, not every linguistic
minority, and/or secure equal status for specific languages,
not every language. While various recommendations for
how the linguistic rights of national minorities can be
secured exist, one can nevertheless conclude that, despite
some differences, there are norms; the recommendations
are all comparable and include central principles with
regard to the language rights obligations of state authori-
ties.42 According to the OHCHR, the private sphere is one of
the most significant areas of language rights, ‘where individ-
ual freedoms and other rights in international human rights
operate to guarantee linguistic freedom in private mat-
ters’.42(p.10) Researchers have found that even the most indi-
genous language minorities in the EU still face losing
linguistic ground in relation to the surrounding majority
language, no matter how active said minorities are.48 Some
‘old’ minority languages are solely used in a single European
state, e.g. Welsh, and such languages can be considered
‘unique’, historical minority languages.44 Other minority
languages are used in more than one European state, with
some languages being a minority language in one state yet a
majority or national language in another state (or vice
versa), e.g. Swedish, Dutch, French and German.44 Some
researchers have maintained that the minority or majority
status of a language community depends on a specific (pol-
itical) context.49 Arzoz maintained that language rights,
according to Green, can be perceived as:
. . . special guarantees accorded to citizens as a ‘natural’
dimension of state-building or re-building, or as part of a
legitimacy bargaining a post-dictatorial or post-racist state
needs to make: if the state wants to have citizens’ trust, it
has to provide for language rights. Thus, language rights
are compromised rights of a fundamental sort.47(p.23)
The actual constitutionalization of language rights is unu-
sual. In both the Canadian Charter of Rights and
Freedoms (CCRF) and the Constitution of Finland, citi-
zens’ language rights are directly recognized and not con-
tingent on legislative implementation.47 In the CCRF and
the Constitution of Finland, the legal effects of what was
essentially a political decision are articulated: the equal
Nordic Journal of Nursing Research 41(1)
standing of English and French in Canada, and Finnish
and Swedish in Finland.
In Finland, for historical reasons, both Finnish and
Swedish are official languages. If one looks more closely
at the Constitution of Finland, with regard to a citizen’s
right to language and culture, it is stated under ‘Basic
rights and liberties’ that:
1) The national languages of Finland are Finnish and
Swedish. 2) The right of everyone to use his or her own
language, either Finnish or Swedish, before courts of law
and other authorities, and to receive official documents in
that language, shall be guaranteed by an Act. The public
authorities shall provide for the cultural and societal needs
of the Finnish-speaking and Swedish-speaking populations
of the country on an equal basis.47(p.29)
Arzoz also maintained that:
Even if formulated as fundamental rights, constitutional lan-
guage rights are not accorded for the sake of freedom and
equality of all individuals and groups living in the state, but
for the sake of basically protecting certain language commu-
nities (for instance, Swedish- and French-speaking citizens in
Finland and Canada respectively).47(p.31)
One can therefore conclude that there is no universal
understanding of language rights, but that they are instead
local, historically rooted claims, and not fixed universals.47
Method
Study design
This was a qualitative study with semi-structured inter-
views. A hermeneutical approach in accordance with
Gadamer50 was used, and the researchers analysed the
data with openness to reveal the subject matter. The data
were analysed through content analysis inspired by
Graneheim and Lundman.51
Participants
The participant group was heterogeneous and consisted of
nine Swedish-speaking Finns, whose mother tongue was
Swedish and who had experience of hospital stays in
Southern Finland. This study differs from other research
on language barriers because the participant group con-
sisted of individuals who were not only minority-language
patients but also members of an indigenous minority. In a
socio-economic sense, comparison can perhaps best be
made to the French Canadians. In this study, the term
‘majority language’ was used to denote the Finnish lan-
guage while the term ‘minority language’ was used to
denote the Swedish language. For more information
about the participant characteristics, see Table 1.
In 2018 the total population of Finland was estimated
at approximately 5.5 million. The two main official
(national) languages are Finnish and Swedish, even
Hemberg and Sved 45

Table 1. Characteristics of the participants.

Marital Retired/
Participant Sex, age status Work/education Hospital experience Hemort working

P1 Female, 71 years Married Economist. Has worked in Hip surgery spring 2018. Helsinki Retired
theatre.
P2 Female, 68 years Married Has worked in insurance. Hip surgery spring 2018. Vanda Retired
P3 Male, 63 years Cohabiting Has worked as seaman, entre- Hip surgery spring 2018. Many Helsinki Retired
preneur and in the national other joint surgeries before.
telephone answering service.
P4 Male, 73 years Married Machine engineer. Has worked Memory examination, doctor’s Helsinki Semi-retired
as consultant. appointments approximately
once a month.
P5 Male, 66 years Married Economist. Has worked in TV Knee surgery summer 2018. Helsinki Works as a
production, and as teacher Ischemic stroke about ten school
and school principal. years ago. principal.
P6 Male, 65 years Married Librarian. Majored in history. Appendectomy a few years ago. Esbo Retired
P7 Female, 77 years Single Nurse aid. Has worked in hos- Has worked in the hospital all Helsinki Retired
pital administration. her working life. Hip joint
operation summer 2018.
P8 Female 65 years Married Librarian. Has worked in a Given birth in the hospital. Has Esbo Works as a
library. accompanied family to librarian.
hospital.
P9 Female, 27 years Dating Economist. Works as consultant. Clot in the lung a few years ago. Helsinki Works as a
Hip operation. consultant.

though Swedish-speaking Finns are classified as an ethnic
minority. Finnish is the majority language, and 4,835,778
individuals were registered in 2018 as having Finnish as
their mother tongue.52 In addition to Finnish and Swedish,
several other languages are spoken in Finland, e.g. Russian,
Arabic, Estonian, English, Somalian and Kurdish.52
Swedish-speaking Finns constitute a significant portion
of the population, numbering approximately 300,000, and
are classified as an ethnic minority.53 They form the largest
minority group in the Nordic countries. In contrast to
many other ethnic minorities, Swedish-speaking Finns
are seen to be healthier, more prosperous, and have greater
life expectancy than the majority population.53 Because
Swedish is an official language, Swedish-speaking Finns
have the right to receive services in their own language.
Furthermore, in those municipalities where at least 8%
of the population or at least 3000 individuals are registered
as Swedish-speaking, state/municipal services in the
Swedish language are guaranteed.42
Patients’ right to service in the national languages of
Finland, in accordance with own language (mother
tongue) is emphasized in the Language Act (423/2003),54
the Constitution of Finland (731/1999)55 and the Act on
the status and rights of patients (785/1992).56 In Section 3
of the Act on the status and rights of patients (785/1992),56 it
is stipulated that a patient’s mother tongue, individual needs
and culture must, to the extent possible, be taken into con-
sideration during care and/or treatment. Furthermore, a
patient has the right to use, be heard in, and obtain docu-
ments containing decisions in the Finnish or Swedish lan-
guage as well as the right to interpretation when using these
languages or translation if the language of an authority or
the language of proceedings is different, rights that are also
mentioned in Sections 10, 18, and 20 of the Language Act
(423/2003).54 In Section 6 of the Health care Act (1326/
2010),57 it is also emphasized that local and joint municipal
authorities shall make healthcare services available in
Finnish or Swedish, with certain provisions made for
whether a municipality is considered unilingual or bilingual.
Data collection – individual interviews
Individuals who had received in-patient care in a care unit at
a hospital in Southern Finland received a written invitation
to participate in individual interviews and were asked to
directly contact the researchers. Six individuals indicated
their willingness to participate in the study in this manner,
and three further individuals were found through snowball
sampling. In total, nine participants were included in the
study. The participants chose the location for the individual
interviews, and all but one interview took place in the
respective homes of the participants, with one taking place
in a café. The interviews lasted between 30 and 60 minutes
and were digitally recorded and transcribed verbatim.
Data analysis
Initially, both researchers read the data several times with
openness. Such reading resulted in the finding of data simi-
larities and differences that transformed the researchers’
understanding. Various meaning units in the data were
highlighted and compiled in a table, in which the research-
ers’ thoughts on the data’s condensed meaning units,
codes, subthemes and main theme were reflected.
46
Table 2. An example of the data analysis process.
Meaning unit Condensed meaning unit
At first things went straight to Not receiving care in the
hell. Then after two weeks patient’s own mother tongue
she received care in Swedish. does not improve his or her
And from then on, things health
really improved . . .
And then a nonchalant behaviour Nonchalant and insulting
from a doctor who obviously behaviour from a doctor
only spoke Finnish, threw her
papers on her stomach. Used
it as a table so to speak. That
made me very sad, but it was
perhaps not the time to ask
the doctor to remove the
papers, that it is her stomach,
and very disturbing to see.
What an attitude!
For an example of this process, see Table 2. The interpret-
ation was a movement between interpretation and
understanding, and between the whole, the parts and the
whole in a spirit of hermeneutics.50 The researchers’
pre-understanding was carefully formulated during the
interpretation to prevent it from steering the interpretation
and was challenged and invited into the scientific dialogue
during the reading to elicit a new horizon of understand-
ing. The data were first analysed separately through indi-
vidual analysis, followed by the researchers jointly agreeing
upon final analysis and abstraction through consensus.
Ethical issues
The study has been conducted in accordance with the
guidelines delineated by the Finnish National Advisory
Board on Research Ethics.58 Ethical permission to conduct
the study was granted by a hospital in Southern Finland.
The participants provided informed consent and were
informed regarding participation in the study, data stor-
age, and data handling for research purposes. The partici-
pants were also informed about the study purpose,
confidentiality, and withdrawal of consent. From an eth-
ical perspective, it was considered defensible to carry out
this study because it might reasonably provide participants
with new insights into their experiences of care.
Results
One main theme and four subthemes emerged from the
findings. The main theme was ‘Quality of care may be
enhanced through care in one’s mother tongue’. The sub-
themes were: ‘Being understood and understanding in a
caring situation provides an increased sense of security’,
‘Being allowed to be oneself eases the patient’s cultural
existence and strengthens communication’, ‘Being treated
as equal decreases suffering related to care and gives the
patient strength’, ‘Being treated with dignity provides well-
being and patients feel they recover faster’ (see Table 3).
Nordic Journal of Nursing Research 41(1)
Code Subtheme Main theme
Violation, Being treated Quality of care
suffering with dignity provides may be enhanced
due to care wellbeing and hastens through care in
recovery time one’s mother tongue
Quality of care may be enhanced through care in one’s
mother tongue
As expressed in the main theme, the quality of care may be
enhanced when care is given in a patient’s mother tongue.
Being able to use one’s mother tongue facilitates commu-
nication, making it easier for patients to express anxiety or
worry or describe feelings of pain in greater detail, which
facilitates pain management. The risks associated with not
receiving care in one’s mother tongue were expressed by
one participant as: ‘. . . one misses important parts that can
both make the situation worse and improve it’ (P9).
Another participant perceived that when one spoke one’s
mother tongue there was better contact with nursing staff
and that it was also much easier to establish good contact
with nursing staff, which is a prerequisite for good quality
care: ‘You feel more understood and the end result is better
[when you speak your mother tongue]. . . to be sure I have
had good contact with [Finnish-speaking] doctors as well
but with Swedish speakers it is always much easier’ (P4).
Being understood and understanding in a caring situation provides
an increased sense of security. Being understood in a caring
situation is an important condition for feeling safe and for
preventing care errors. When ill or weak, patients may find
it difficult to communicate in a secondary language, and
miscommunication can result in patients feeling unsafe or
the occurrence of care errors. One participant mentioned
an emergency healthcare situation, where he as a patient
waited several hours for a doctor who spoke his mother
tongue to come to speak to him. While waiting for the
doctor there had been several misunderstandings and the
patient, not understanding what was happening, began to
panic and feel as if he were receiving inadequate treatment:
I had misunderstood the situation. It was later revealed
that I had a [blood clot in my lung] and they talked a lot
about how it went through the heart and so on. So I mis-
understood where it was. (P9)
Hemberg and Sved 47

Table 3. Main theme and subthemes.

Main theme Subthemes

Quality of care may be enhanced
through care in one’s mother tongue
Being understood and understanding in a caring situation provides an increased sense
of security
Being allowed to be oneself eases the patient’s cultural existence and
strengthens communication
Being treated as equal decreases suffering related to care and gives the patient strength
Being treated with dignity provides wellbeing and patients feel they recover faster

Often it is not until after an emergency situation that patients
have time to reflect on their traumatic experiences of suffer-
ing related to care, and being unable to immediately process
their experiences can make them sad, nervous or unhappy.
The participants noted that they did not wish to compromise
the nurse–patient relationship by ‘demanding’ care in their
mother tongue, given that they were in a vulnerable situation.
The participants perceived that nurses could be reluctant to
switch to the minority language and felt as if they would be
‘forcing’ the nurses to switch languages, which could cause
the participants to feel unsafe. One participant mentioned
that she experienced that she was not taken seriously when
she told her caregivers that her Finnish was not very good,
noting that the nurses took no notice of her comment and
continued to speak Finnish with her.
I felt very weighed down by this, very sad. The circum-
stances of the illness had already made me nervous and
then not understanding what was going on . . . it tends to
make you a little nervous. Not understanding everything
does not exactly make you calm. (P9)
The participants mentioned that not being able to
understand their health condition was mentally very diffi-
cult and could cause discontent, worry, and a sense of
feeling unsafe. As one participant noted: ‘You may
think it is more serious than it is or that it is not as serious
as it is’ (P9).
The participants maintained that when they were ill or
in critical condition, they often lacked the strength to
actively demand good care, because they were in a vulner-
able situation and did not wish to compromise their rela-
tionship with nurses by insisting on care in their mother
tongue. One participant mentioned that language prob-
lems lead to her feeling unsafe and becoming worried
about the quality of care she received:
. . . being in a vulnerable situation such as in the hospital
you do not want to make your position worse in relation to
doctors and so on. I felt unsafe and it was not like they
were mean or anything, but you know that they do not
really want to speak [my mother tongue, Swedish] and if
they have to do it in certain situations you wonder if they
do their best or not. (P9)
The participants mentioned that the perception that nurses
were trying their best to speak the patient’s mother tongue
could instil a sense of safety and feeling of satisfaction,
resulting in an increase in patients’ understanding and
trust in the care received. As one participant related:
It is always a question of a sense of safety, and certainly
it to be sure gives you a greater sense of safety if you
know that you can communicate in your own language.
(P5)
Being allowed to be oneself eases the patient’s cultural existence
and strengthens communication. It is important that patients
be allowed to be themselves and experience mutual under-
standing in the caring situation. The participants equated
the experience of being allowed to be oneself with a sense
of relief and feeling of satisfaction that in turn eased the
patient’s existence. The participants also mentioned that
not needing to translate words associated with their con-
dition allowed them to fully focus on themselves and own
feelings of, e.g. pain. As one participant noted:
Yes, relieved! You feel relieved. And when you are ill you
want your mother tongue even if you know the other lan-
guage equally well, but at that time you want care in [your
mother tongue]. It feels good. (P3)
Allowing patients to be themselves, e.g. speak their mother
tongue, allows them to listen and express their own needs
and desires, that is to say it strengthens communication.
Allowing patients to speak their mother tongue also sup-
ports nonverbal communication, which in turn facilitates
nurse–patient communication in a way not possible when
patients must speak a secondary language. As one partici-
pant related:
Yes, and it is not just a question of words, but our whole
culture, what we do not express in words but still commu-
nicate to each other. (P1)
The participants also revealed that when speaking their
mother tongue it was easier to express themselves and
remember what they wanted to discuss:
A thorough discussion is easier in your mother tongue and
it is easier to remember to raise specific issues [about your
health] in your mother tongue. (P4)
The participants related that they felt relieved when they
could speak their mother tongue in a caring situation,
48
because they understood what was being said and felt they
themselves were understood. Using their mother tongue
also gave them the courage to communicate in a direct
and to the point manner and eliminated the need to
search for words and/or expressions.
Being treated as equal decreases suffering related to care and gives
the patient strength. Perceiving that one is treated as equal in
the care relationship is important, because it decreases suf-
fering related to care, and being able to speak one’s mother
tongue helps create the sense that one is ‘equal’. The par-
ticipants expressed that they could experience a sense of
inequality in the care relationship when using their
mother tongue, if this coincided with them expressing
themselves using the minority language. Patients whose
mother tongue is the majority language or who possess
sufficient proficiency in the majority language can ask
more questions, discuss the care situation in more detail
and enquire about alternative care methods. When nurses
speak their patients’ mother tongue they demonstrate dig-
nity, even if their language skills are somewhat lacking,
which in turn can instil patients with a sense of calm
and safety:
Then I would say that you become much calmer just by
receiving that understanding, that, OK, I do not know
much [of your mother tongue] and you do not know
much [of my mother tongue] but that we try to get it
right is important. (P9)
Still, the participants also noted that suspended care could
arise from caregivers continuing to speak the patient’s
mother tongue even when the caregivers were not fully
proficient in the minority language:
I have sometimes encountered doctors who wanted to prac-
tice their Swedish with me and this shows a positive atti-
tude, but it comes to nothing and then I switch to
Finnish. (P1)
The participants also mentioned that suffering related to
care could arise from language barriers. One participant
spoke of feeling ignored when her nurses replied and
continued speaking to her in the majority language,
even though the participant was not sufficiently proficient
in the majority language to express herself and instead
spoke to the nurses in her mother tongue. This created
suffering related to care. The participants also mentioned
that they often perceived that when they spoke their
mother tongue (the minority language), nursing staff
could demonstrate an unwillingness to treat them with
kindness or respect and that nursing staff could use body
language to express opposition to speaking the minority
language:
. . . to be treated as ‘difficult when you come here and speak
Swedish’ does not make things better. And then you start
to wonder if you have a big problem or what is the
cause. (P9)
Nordic Journal of Nursing Research 41(1)
Being treated with dignity provides wellbeing and patients feel they
recover faster. Receiving care in one’s mother tongue
increases patients’ wellbeing and decreases recovery time.
When nurses speak their patients’ mother tongue, they see
each patient as a whole human being and demonstrate
kindness and dignity, which can positively influence
patients’ recovery because patients then experience that
they are seen. Care in one’s mother tongue results in
fewer misunderstandings and patients can more easily
ask relevant questions, which simultaneously increases
patients’ sense of being treated as equal. The participants
maintained that receiving care in one’s mother tongue also
affected how they experienced their hospital stay and could
make them more positively disposed toward care. When
patients do not have proficiency in the majority language,
they can experience that they are not taken seriously as
individuals, which is the antithesis of person-centred
care. When patients receive care in their mother tongue,
how they perceive the quality of the care they receive can
be influenced:
I was really happy [to have a physiotherapist who could
speak my mother tongue]! I met her already before the
surgery, and it made my attitude toward this whole surgery
very positive . . . It made my stay there much better. (P1)
The participants noted that their mother tongue was also
their language of emotion and that, consequently, the
nurse–patient relationship could become closer if they
were allowed to speak their mother tongue. Speaking
one’s mother tongue allows patients to feel recognized
and experience dignity, which can affect patients’ recovery
in a positive way and contribute to a quicker recovery. The
importance of receiving care in one’s mother tongue espe-
cially emerges in the context of psychiatric care, as one
participant noted:
At first things went straight to hell. Then after two weeks
she received care in [her mother tongue]. And from then
on, things really improved . . . (P1)
The participants experienced that older patients whose
mother tongue was Swedish were a vulnerable group in
Finland and that such individuals have often not been
met with the respect or dignity that they deserve when in
care because they speak a minority language. The partici-
pants even mentioned that their next of kin found it
important that nursing staff used patients’ mother tongue
when providing care, because this demonstrated that the
nursing staff respected the patients and thereby met them
with dignity. One participant mentioned a situation where
emergency care was required but none of the emergency
nurses spoke the patient’s mother tongue, furthermore
expressing the view that the nursing staff were not even
apologetic about their obvious indifference. The perception
that patients are ‘disregarded’ when in care because of their
mother tongue can create a sense of frustration in next of
kin. The participants also perceived that it could be ‘chal-
lenging’ for next of kin to demand that nursing staff speak
Hemberg and Sved
patients’ mother tongue and that next of kin could experi-
ence such situations as being offensive or even ‘hurtful’,
and could even cause next of kin to become speechless in
the situation:
And then a nonchalant behaviour from a doctor who obvi-
ously only spoke [the majority language], threw her papers
on [the patient’s] stomach. Used it as a table so to speak.
That made me very sad, but it was perhaps not the time to
ask the doctor to remove the papers, that it is [the patient’s]
stomach, and very disturbing to see. What an attitude! (P8)
The participants also expressed frustration over situations
where next of kin were asked to act or acted as language
brokers. In such situations, the participants perceived that
patients were made vulnerable and their autonomy com-
promised: patients became fully dependent on their next of
kin and confidentiality could be broached when issues of a
private nature were discussed.
Strengths and limitations
One limitation might be the limited number of participants
(nine). Strengths, however, were that the participant group
was heterogeneous and the participants were willing to
share their experiences in face-to-face interviews, which
yielded rich data and a nuanced picture of receiving care
in one’s mother tongue. Validity was ensured when both
researchers first individually conducted an initial analysis
and then reached consensus on the final abstraction and
final analysis.
Discussion
The aim of this study was to explore the importance for
patients of receiving care in their mother tongue. We found
that receiving care in one’s mother tongue was connected
to quality of care. Receiving care in one’s mother tongue
was crucial for patients’ sense of safety and eased their
cultural existence, and the realization of such presupposed
nurses’ cultural and ethical competence.28 We saw that
patients’ sense of safety and trust in the care being pro-
vided increased when nursing staff accommodated patients
in their need to receive care in their mother tongue, even if
the nursing staff’s proficiency in the patients’ mother
tongue was lacking. It is essential that nurses express them-
selves in a language that patients understand.59 Patient
trust in the care being provided is important with regard
to whether patients accept the care being offered, and over
time this can contribute to the quality of care.18
Nevertheless, Sze-Mun Lee et al.39 emphasized that there
are risks (e.g. misunderstandings, care errors) associated
with nursing staff using simplified language with patients,
which often occurs with minority-language patients, and
even vice versa, when patients use simplified language
with nursing staff.39
Researchers33–35 have found previously that the use of
professional interpreters can generally be considered a
good, cost-saving and care-improving measure and that
49
using professional interpreters is even better than nursing
staff using limited language skills. Still, we maintain that
the use of professional interpreters might not be solely
positive in contexts similar to the context seen in this par-
ticular study: a country with two official languages and
where majority and minority language speakers are
afforded equal language rights.47 While patients can
receive care in their mother tongue either via nursing
staff or professional interpreters, this does not guarantee
or even imply that minority-language patients then receive
advanced care in their mother tongue. We maintain that
the optimal situation would include the provision of care
by nursing staff who are proficient in both the majority and
minority languages and who possess specialized language
skills. Other researchers have found that if only a few
nurses or a single nurse possess both specialized language
skills (context-specific and which facilitate communication
with minority-language patients) and advanced nursing
skills, this can affect the nurse-to-nurse care relationship
in a unit.9 We therefore recommend that arrangements be
made so as to ensure that several such specialized and
highly skilled nursing staff are working at all times.
We saw that the participants perceived that it could be
necessary to not speak their mother tongue and instead
speak the majority language used by nursing staff, e.g.
when nurses’ knowledge of the minority language was
insufficient. The risk of misunderstandings increases
when patients use a language other than their mother
tongue.18,21,60 Previous studies have shown that the more
serious the illness the more important it is for patients to
express themselves in their mother tongue.18,61 When there
are time pressures and it is difficult to find the right words,
patients can feel unsafe and their anxiety can increase.
Misdiagnoses can also increase when nurse–patient com-
munication is compromised.61 Not being understood and
not understanding can be considered suffering related to
care, where patients feel unsafe, sad, shameful and alone.62
Suffering in care can, in turn, lead to a worsening of
patients’ symptoms of illness.53 When patients feel that
their mother tongue is respected by nursing staff, patients’
feelings of loneliness and alienation can decrease. We saw
here that the participants often experienced suffering
related to care and could feel that their rights were com-
promised when they did not receive care in their mother
tongue. Language barriers can result in patients perceiving
a person speaking another language as being terse or
rude,18 because language touches upon a significant emo-
tional dimension and helps preserve personal and linguistic
identity.42,47 The participants in this study maintained that
they could experience a sense of not being equal in the care
relationship when using their mother tongue and that nur-
sing staff did not take them seriously when a lack of skill in
the majority language, which the nursing staff spoke, was
admitted.
Patients in Finland have the right to service in the
national languages of Finnish and Swedish, in accordance
with their own language (mother tongue), as emphasized in
the Language Act (423/2003),54 the Constitution of
Finland (731/1999)55 and the Act on the status and rights
50
of patients (785/1992).56 In the healthcare context in
Finland this includes more than the right to receive infor-
mation about one’s care in one’s mother tongue (often via
professional interpreter), as is seen in other countries where
minority languages are not granted ‘official language’
status. Finland presents a special case because of its two
official languages: while Finnish-speaking healthcare staff
are not required by law to speak Swedish with Swedish-
speaking patients, Swedish-speaking Finns have the right
to speak Swedish with all healthcare staff.54,56 Therefore,
not receiving care in Swedish can lead Swedish-speaking
Finns to perceive that their rights are being compromised
and that they as human beings are not being treated with
dignity, when they are misunderstood, not taken seriously
or not treated as equal to those who speak the majority
language.47
Overcoming linguistic difficulties by using professional
interpreters is, in a setting such as seen in this study, there-
fore problematic. Granhagen Jungner et al.40 found that
translating and transferring information is problematic,
because cultural issues can lead to cultural misunderstand-
ings and clashes. Also, acting as a neutral interpreter in a
situation where a cultural link is needed is difficult, because
interpreters may ‘context adjust’ their translations.40
Moreover, Bischoff et al.6 saw that interpreters also take
into account wider cultural and political contexts rather
than solely translating word-for-word. In a healthcare con-
text, interpreters must have the understanding and ability
to handle cultural divergences between staff, patients and
families.40 Bischoff and Hudelson63 suggested that lan-
guage services should be integrated into healthcare organ-
izational routines to address any eventual problems that
clinical staff may have with regard to interpreters.
The caring relationship is compromised when patients
perceive that they have been treated in an offensive way,
seen in this study as next of kin perceiving that they needed
to ‘demand’ that nursing staff provide care for patients in
the patients’ mother tongue. Patients can experience shame
if they cannot speak the majority language sufficiently well,
which, in turn, causes suffering related to care. Patients can
also begin to question their condition and even whether
they need care at all, which, at worst, can lead to hesitation
in seeking help, so as to avoid language problems and
shame. The harmful experience of not being treated as
equal in the caring relationship has a profoundly negative
effect on patients’ wellbeing and health, and nursing staff
should recognize that minority-language patients are vul-
nerable in the caring relationship. Alpers25 found that dis-
crimination in healthcare occurs and that it can lead to
racial and ethnic health inequities that negatively affect
health outcomes.64,65
Allowing patients to receive care in their mother tongue
helps preserve patients’ identities and can ease patients’
cultural existence. Patients can be themselves when speak-
ing their mother tongue and be seen as a whole human
being, which in turn strengthens communication in the
caring relationship because it helps patients express them-
selves and their needs more precisely. When patients are
allowed to speak their mother tongue, non-verbal
Nordic Journal of Nursing Research 41(1)
communication is also supported and more evidently con-
tributes to understanding. Sze-Mun Lee et al.39 saw that
non-verbal communication can easily lead to misunder-
standings because, e.g. a gesture can mean different
things depending on cultural context. Also, Züllich
et al.66 found that when nursing staff and patients share
the same mother tongue and linguistic culture, the patients’
culture is taken into consideration and nurses’ non-verbal
communication is more understandable for patients.
As seen here, speaking one’s mother tongue allowed
patients to feel recognized, seen and as though they were
equal. It allowed them to to experience dignity in the
caring relationship, which positively influenced their recov-
ery and improved perceived quality of care. Not receiving
care in one’s mother tongue could cause discontent, worry,
and a sense of feeling unsafe. Taylor et al.31 found that
when an individual is subjected to stress, he/she often finds
it difficult to understand and remember instructions.
Consequently, when nurses cannot speak a patient’s
mother tongue, a personal and loving presence becomes
even more meaningful.62
To improve the quality of care and ensure that patients
can receive care in their mother tongue, those who employ
nurses should consider language skills to be an important
attribute. Truong et al.28 suggested that it would in certain
instances be appropriate to hire healthcare staff from vari-
ous ethnicities and minorities, because such employees can
possess valuable knowledge of their own culture and con-
sequently better understand patients from the same cul-
ture. If nurses have good knowledge of a minority
language, this can imply that they also have a positive
attitude toward that particular language.37 Healthcare
organizations should support nurses by organizing for
them language courses in a country’s minority language,
because such courses are useful in positively changing
negative attitudes toward a minority language.37
This study also shows that patients were made vulner-
able and that their autonomy was compromised when their
next of kin were asked to act or acted as language
brokers. According to Sze-Mun Lee et al.,39 having next
of kin as language brokers may be problematic in caring
situations, because confidential and sensitive matters may
be revealed which would compromise confidentiality and
patients’ right to dignity. Also, if language brokers are
dominant and excluding in their roles67,68 or ‘speak as
themselves’ rather than accurately transferring informa-
tion,67–69 they can have a negative effect on the caring
relationship.
Receiving care in one’s mother tongue entails being
treated with dignity and seen as a whole person.62 Being
included by health professionals can instil patients with
courage and inner strength70 as well as confidence and
trust.71 Respectful treatment, where caregivers are kind
and create space for patients and their next of kin to par-
ticipate in care, results in patient satisfaction with care.72
According to Eriksson,73 poor treatment or lack of eye
contact may extinguish a patient’s last spark of joy.
Being forced to translate or search for words in a second
language is tiring, especially if one has a serious illness.
Hemberg and Sved
Earlier research shows that even if nursing staff can only
talk about everyday matters in a patient’s mother tongue,
this helps create a good nurse–patient relationship.37
Related to this, a new finding was seen in this study: that
patients’ next of kin also experienced it as being tiring
when patients did not receive care in their mother tongue.
As seen in the results, quality of care may be enhanced
through care in one’s mother tongue. The participants
clearly perceived that care in one’s mother tongue provided
a sense of safety, improved communication and under-
standing and contributed to patients’ wellbeing and
strength. Also, we saw that using patients’ next of kin as
language brokers should be avoided, because this can com-
promise the wellbeing and dignity of both patients and
their next of kin.
Conclusions
Receiving care in one’s mother tongue leads to the percep-
tion of quality of care for patients and their next of kin,
and the realization of such presupposes nurses’ cultural
and ethical competence. Supporting nurses’ language
skills and encouraging them to use these in care are import-
ant means whereby suffering related to care resulting from
language barriers can be reduced. Further research should
focus on nurses’ perspectives on the significance of minor-
ity-language patients using their mother tongue in a nur-
sing context.
Acknowledgements
The authors would like to thank the individuals who participated
in this study.
Author contributions
Jessica Hemberg contributed to the study conception and design,
data analysis, discussion, and drafted the manuscript at all stages.
Emilie Sved contributed to the study conception, data collection,
background and discussion.
Conflict of Interest
The authors declare that there is no conflict of interest.
Ethical approval
The study has been conducted in accordance with the guidelines
delineated by the Finnish National Advisory Board on Research
Ethics (2012). Ethical permission to conduct the study was
granted by a hospital in Southern Finland. The participants pro-
vided informed consent and were informed regarding participa-
tion in the study, data storage, and data handling for research
purposes. The participants were also informed about the study
purpose, confidentiality, and withdrawal of consent. From an
ethical perspective, it may be defensible to carry out this study
because it might reasonably provide new insights for the partici-
pants from reflecting on their experiences of care.
Funding
The Swedish Cultural Foundation in Finland has generously pro-
vided financial support for this study.
51
ORCID iD
Jessica Hemberg https://orcid.org/0000-0002-0829-8249
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