The Equality Act (2010) requires all services to be equally accessible for patients, regardless of who they are. This case review evaluates a patient whose first language is not English and will explore the challenges surrounding that, particularly as healthcare professionals are expected to tailor services to individuals (NICE, 2012). The main considerations of this case will be identification, ‘LMP’ and consent, all of which are morally, ethically and legally required to be obtained for any examination (Department of Health (DH), 2009). Different types of communication, the question of consent, interprofessional relations and interacting with patient’s families will also be discussed, considering the best and safest results for the patient. A challenge with this patient is establishing an effective means of communication, as their first language is not English.
Communication, a meaningful exchange that gives thoughts, opinions, and feelings, verbally and non-verbally, is essential to the healthcare profession (DH, 2010) and can impact the way a patient feels and responds to healthcare staff when in their care. Under the Equality Act (2010), providing patients with equal access to services is a requirement and establishing the most effective way of communicating with patients can solve this. Good communication can make patient’s more comfortable and cooperative. This is important in Radiography, as patients are instructed when positioning and their details and consent being confirmed is a legal requirement (DH, 2013). Patients who cannot speak English might not be able to give ‘informed consent, ask questions or understand their rights and responsibilities in the NHS (Trust A, 2010).
However, it is important to treat all patients with respect and dignity, which is not just a legal responsibility but an ethical one, and providing effective communication is included in this (Trust B, 2016). The patient cannot speak English and her husband, who has chosen to translate for her, is limited in his English so establishing an effective means of communication is vital and this is likely to be achieved through interpretation. Hudelson and Vilpert (2009) suggest that the quality of healthcare is compromised when patients who require linguistic assistance do not get interpreters. This can negatively affect patient and staff satisfaction (Bagchi et al, 2011).
It is important to recognise the challenges of language barriers but achieving ‘high quality, patient-centred care’ is dependent on sufficient communication, listening and understanding the patient’s needs (Hudelson and Vilpert, 2009). The NHS is committed to providing a service that meets the needs of all patients, including those with language barriers, and recommends that only qualified interpreters are used to translate between staff and patients (NHS England, 2015). The patients’ husband has chosen to translate for his wife, but he could translate incorrectly which could have implications (Flores et al, 2012) and using family members to translate is not considered good practice. Trust C, states that all patients have the right to communication support. In emergencies, they recommend using telephone interpreting which has no waiting time, compared to a face-to-face interpreter who could take several hours (Trust C, 2017a). This is similar in Trust B (2016), who has an Emergency translation service that can be used out of hours. It could be argued that although the patient is benefiting from having linguistic assistance which positively affects their satisfaction and quality of care (Karliner et al, 2007), providing them with equal access to services, they could lose out from face-to-face communication which could hinder the process of developing a positive patient-staff relationship which is important for patient centred care (Ramlaul and Vosper, 2013). However, by providing translation services, the radiographer is adhering to the HCPC’s standards which requires staff to make arrangements and meet the patient’s communication needs (HCPC, 2016).
Alternatively, an Emergency Multilingual Phrasebook, which is in all A departments in England (DH, 2013) can be used. Created by the British Red Cross in 2004 it includes several translated phrases, including ‘Last menstrual period’ (British Red Cross, 2004). This not only complies with the HCPC’s Standards of conduct but applies a patient centred care approach as the patients’ needs are being met. Epstein and Street (2011) stress the importance of patient centred care arguing it improves the work ethic of staff as patients are generally more cooperative.
Wasson et al (2008) supports this, suggesting that good patient centred care benefits staff as well as patients as they can work better knowing they have satisfied their patient’s needs. However, the phrasebook is only available in 36 languages and states that ‘efforts should always be made to obtain an interpreter’ (British Red Cross, 2004). Unfortunately, the use of interpreting services is not always used in clinical practice. Students have witnessed radiographers relying on family members to translate which is regarded as bad practice (Trust B, 2016). Another concern is the patient’s husband who insists on staying in the room to translate for his wife. As said, using family to translate is considered bad practice but if the patient elects to use a family member to translate, they can.
However, radiographers are expected to advise the patient on any risks, that is it not recommended and that the Trust cannot take any responsibility for errors. If the patient still agrees, it must be noted in their health record (Trust A, 2010). The radiographer must consider that the patient’s husband is likely to be worried about his wife and show empathy.
Omole et al (2011) supports this, arguing that the role of family members is important and when interacting with them one must recognise and acknowledge any expressed emotions. Poor communication between hospital staff and family can cause distress and dissatisfaction and is a common topic of complaint in the NHS (Ombudsman, 2013). However, it is imperative this does not get in the way of good practice. The patients’ husband being in the room also puts him at risk of receiving unnecessary radiation. Not only that, but it may compromise patient confidentiality, of which the NHS is committed to (NHS England, 2016). The patient may not want him in the room and due to the language barrier, this could be difficult to communicate. Another thing to consider is the examination room’s control area, where other patient’s clinical details may be visible on computer screens and having the patient’s husband in this space may compromise the confidentiality of other patients, not fulfilling the duty of an HCPC registrant (HCPC, 2016). Unless the patient has sufficiently demonstrated that she would like her husband in the room to translate (Trust A, 2010), the radiographer has a duty to ask him to leave.
Alternatively, the patient’s husband could wait behind the screen with the Radiographer during exposure but stay with his wife, during the processing of the radiograph but this is dependent on Trust Policy. It is important to acknowledge that the Radiographer should always feel safe. In cases where the patient’s husband’s insistence becomes aggressive, the Radiographer has every right to ask for assistance in removing him from the department as a healthcare professional’s safety should never be compromised. This is a pledge, highlighted in the NHS constitution (NHS England, 2015).For the examination, it is expected the radiographer will introduce themselves, applying the 3-point-check (Gudla et al, 2014) where the patient’s full name, date of birth and 1st line of their address would be confirmed. This is a legal requirement, highlighting the importance of correctly identifying patients.
In radiography, where ionising radiation is used, the implications of exposing the wrong patient are significant due to the stochastic and deterministic effects of radiation (WHO, 2007; Ball et al, 2008). In the case of this patient, confirming these details could be a challenge as they may not understand what the Radiographer is asking of them, but it is important to not assume as this can lead to poor care (Grimley, 2017). At this point, the Radiographer could ask the patients husband, but it is preferable to ask the patient herself and this is where different means of communication may have to be adopted. The Radiographer could consider asking the patient ‘what is your birthday?’ or ‘where do you live?’ instead of ‘date of birth’ and ‘1st line of address’ which could be considered more formal. Alternatively, the Radiographer could rely on non-verbal cues.
However, with non-English speaking patients, obtaining a translator is the optimal option. The focus of this case is establishing the patient’s Last Menstrual Period (LMP). LMP is the ‘first day of your last period’ (the ’28-day rule’) and is asked to female patients, between 12-55 for radiographic examinations below the diaphragm and above the symphysis pubis (The Royal College of Radiologists (RCR) 2013) and abdominal radiographs are included in this. Establishing female patients LMP is not only a legal requirement under the Ionising Radiation (Medical Exposure) Regulations (2017) but is important for establishing whether a patient is pregnant or not. This is important because of potential stochastic and deterministic effects of radiation and the risk of malignancy this may have on a developing foetus (RCR, 2013).
This highlights the significance of correctly identifying a patient’s LMP as the risk can have a ‘negative’ outcome as cells are the most sensitive to ionising radiation at this point (Shaw et al, 2011). Article 20 of the European Communities (Medical Ionising Radiation Protection) Regulations 2002), states that the practitioner should inquire if a patient is pregnant and record her response and when unable to confirm pregnancy, the patient will be treated as though she is pregnant (HSE, no date). Based on the law, it is likely the referrer had confirmed pregnancy, possibly by using a pregnancy test.
However, LMP must still be established. Modalities that do not use ionising radiation like MRI and Ultrasound (Health Protection Agency et al, 2009) could be considered. Regarding MRI, its safety in the first trimester of pregnancy is still subject to discussion. There is no overwhelming evidence of unsafety in early pregnancy, as studies have been small, but the main concerns raised have been potential teratogenic effects through heating and causing acoustic damage to a developing foetus (Bulas and Egloff, 2013). Similarly, the use of gadolinium (an MR specific contrast agent) any time in pregnancy is associated with an increased risk of dermatological conditions and stillbirth (Hellwig, 2016). However, this patient was brought into AAE in the night where the main department would have been closed and it is unlikely they would have been an option. CT is an alternative imaging modality, which is available after hours and is more sensitive than plain film imaging, demonstrating the cause of obstruction in approximately 80% of cases (Brant and Helms, 2007).
However, if the patient was pregnant this modality would not be considered due to its high ionising radiation dose compared to digital radiography (Ball et al, 2008). This shows the significance of correctly establishing LMP as it enables the most appropriate patient care pathway.Hopefully, with the use of translation services, the radiographer can confidently establish the patient’s LMP. If not, according to Trust C (2016b), the operator should send the request back to the referrer. However, it is important to consider that the patient has been brought into AAE with an acute presentation, so it is a medical emergency. The radiographer could speak to the referrer and explain the situation, stating that the patients LMP could not be confidently confirmed and if the referrer is content, the radiographer can note that they have talked to them in the patient’s notes and it is suitable to continue with the abdominal examination.
This demonstrates working inter-professionally, which is a huge part of the radiography profession and satisfies the requirements of keeping a record of work (HCPC, 2016) It also adheres to the IR(ME)R 2017 requirements, whereby the role of the operator has been fulfilled. The clinical details stated query ‘obstruction’, which is within the referral criteria for an Abdominal Radiograph (Trust C, 2016c). However, it is the only clinical detail listed, which demonstrates poor inter-professional communication on the Referrer’s part. Strudwick and Day (2014), touch on this in their paper ‘Inter-professional working in diagnostic radiography’ which discusses communication between different professional groups. Alternatively, the lack of detail could be intentional. AAE departments are often busy and time is a factor that must be considered.
Students have witnessed this, where referrers would request examinations, knowing it was justified, meeting the referral criteria but include very little detail. This could be due to time constraints and the increased pressure in the NHS, but research conducted by the Medix Consultancy found 83% of doctors had carried out treatment they considered unnecessary, with 63% proceeding due to fear of litigation or driven by patient pressure (Donnelly, 2016). However, although brief, the details were suitable, and the examination could be justified under IR(ME)R 2017. Considering these factors, communicating effectively with the patient is highly important, querying their signs and symptoms, as it is the responsibility of radiographers to justify all examinations as required under IR(ME)R 2017.
Further to that, Ploussi and Efstathopoulos (2016) mention the importance of having a ‘radiation protection culture’ in radiology departments, further supporting the idea of every examination being justified. Before positioning the patient, it is very important to establish ‘valid’ consent, a legal and ethical principle (DH, 2009) and is a duty of HCPC registrants (HCPC, 2016). This can be interpreted in the Human Rights Act (1998) and the NHS constitution, which pledges to offer what is necessary for the patient to participate in their own decisions and this extends to providing translation services, (NHS England, 2015) and healthcare professionals are expected to apply this to practice (DH, 2009). This is important in all cases unless a patient is deemed to not have the mental capacity to make decisions in their best interests (Mental Capacity Act, 2005).
For this case, different types of consent must be considered. Chambliss et al (2010) describes several types of consent, including informed and implied. All patients have the right to refuse treatment, even if the referrer has initially obtained consent (SCoR, 2007) and this extends to who they want to treat them. Radiographers are expected to introduce themselves and talk to the patient at the beginning of the examination. Not only does this establish a positive relationship with the patient but them actively participating with the radiographer, implies consent.
This may be difficult for this patient, who may struggle to verbally communicate but coming into the examination room and engaging with the radiographer, is suggestive of giving consent Chambliss et al (2010). However, it is important to correctly distinguish between compliance and consent which is demonstrated through behaviour (SCoR, 2007). The SCoR (2007) describes the ‘provision of information’ as central to the process of consent. Patients are entitled to have information provided prior to any procedure and as the patients cannot speak English, there is the concern that ‘valid’ consent may be difficult to acquire. Radiographers have a duty of care to inform patients of the risks and benefits of any procedures they are going to undertake as well as ensure they understand that they can change their minds at any time (SCoR, 2007). If the radiographer establishes consent from the patient, they should proceed with the radiographic examination. Assuming interpretation services are being used, the radiographer will have to consider non-verbal communication with the patient. This will include considering their tone of voice, keeping eye contact and considering their facial expressions, all of which can determine the way a patient interacts with staff (Montague et al, 2013).
Despite the language barrier, the Radiographer must show they are there for the patient adopting a patient centred approach (NHS England, 2015). After the examination and checking the radiographs obtained are diagnostic (HCPC, 2016) the radiographer must communicate with the patient about what to do next, dependent on Trust Policy. As the patient does not speak English, this information is likely to be passed onto her husband or to the patient via the interpreter. To conclude, there are several concerns dealing with a patient whose first language is not English. However, as the NHS Constitution states, every patient is entitled to equal access to services and in reviewing this case, this was considered.
This case review has taken a critical approach to the identification of the patient, establishing LMP and gaining consent, all legal requirements in healthcare, all whilst considering the implications of a non-English speaking patient. It is the duty of radiographers to ensure their patients are appropriately cared for and their needs are met when in their care, regardless of the challenges involved.