Open access
Quality and safety issue: language
To cite: Al-­Yateem N, Hijazi H,
Saifan AR, et al. Quality and
safety issue: language barriers
in healthcare, a qualitative
study of non-­Arab healthcare
practitioners caring for Arabic
patients in the UAE. BMJ Open
2023;13:e076326. doi:10.1136/
bmjopen-2023-076326
► Prepublication history and
additional supplemental material
for this paper are available
online. To view these files,
please visit the journal online
(http://dx.doi.org/10.1136/​
bmjopen-2023-076326).
Received 04 June 2023
Accepted 23 November 2023
© Author(s) (or their
employer(s)) 2023. Re-­use
permitted under CC BY-­NC. No
commercial re-­use. See rights
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BMJ.
For numbered affiliations see
end of article.
Correspondence to
Professor Nabeel Al-­Yateem;
​nalyateem@​sharjah.a​ c.​ae
barriers in healthcare, a qualitative
study of non-­Arab healthcare
practitioners caring for Arabic patients
in the UAE
Nabeel Al-­Yateem ‍ ‍,1 Heba Hijazi,1,2 Ahmad Rajeh Saifan,3 Alaa Ahmad,4,5
Rami Masa'Deh,3 Intima Alrimawi,6 Syed Azizur Rahman,1
Muhammad Arsyad Subu,1 Fatma Refaat Ahmed ‍ ‍1,7
ABSTRACT
Objectives To identify language-­related communication
barriers that expatriate (non-­Arabic) healthcare
practitioners in the UAE encounter in their daily practice.
Design Qualitative study utilising semi-­structured in-­
depth interviews. The interviews were conducted in
English language.
Setting Different healthcare facilities across the UAE.
These facilities were accessed for data collection over a
period of 3 months from January 2023 to March 2023.
Participants 14 purposively selected healthcare
practitioners.
Intervention No specific intervention was implemented;
this study primarily aimed at gaining insights through
interviews.
Primary and secondary outcomes To understand the
implications of language barriers on service quality, patient
safety, and healthcare providers’ well-­being.
Results Three main themes emerged from our analysis
of participants’ narratives: Feeling left alone, Trying to
come closer to their patients and Feeling guilty, scared and
dissatisfied.
Conclusions Based on the perspectives and experiences
of participating healthcare professionals, language
barriers have notably influenced the delivery of healthcare
services, patient safety and the well-­being of both patients
and practitioners in the UAE. There is a pressing need,
as highlighted by these professionals, for the inclusion of
professional interpreters and the provision of training to
healthcare providers to enhance effective collaboration
with these interpreters.
INTRODUCTION AND BACKGROUND
Communication is a vital component of
human interaction and daily life activities.
Clear communication is also critical for
healthcare systems because the delivery of
effective, high-­
quality and safe healthcare
services depends on accurate communica-
tion. A 2015 report from the Harvard Medical
Institution Risk Management Foundation
Al-­Yateem N, et al. BMJ Open 2023;13:e076326. doi:10.1136/bmjopen-2023-076326
Original research
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STRENGTHS AND LIMITATIONS OF THIS STUDY’
⇒ The study employed a qualitative phenomenological
design and purposive sampling, effectively captur-
ing diverse healthcare practitioners' experiences
with language barriers.
⇒ Comprehensive data was collected via in-­ depth
interviews, with Van Manen’s method ensuring de-
tailed and structured analysis.
⇒ The research team’s mixed academic and clinical
background further enriched study interpretations.
⇒ Participants might have under-­reported challenges
due to career implications and potential restraint
from recording during interviews.
investigated communication failures in
healthcare and noted that in the USA, patient
harm was directly connected to communica-
tion in 7149 cases.1 In addition, the report
found that 44% of these communication fail-
ures caused severe harm (including death),
44% caused moderate severity harm and 12%
caused low severity harm; these cases resulted
financial losses for the healthcare system of
about US$1.7 billion.
The UAE, a Middle Eastern nation
comprising seven emirates and home to
around 10 million people, is thriving both
economically and politically. It stands out
as one of the wealthiest, most peaceful and
stable countries in the region. Its remarkable
economic success and rapid development
in various sectors have made it a magnet for
expatriates seeking employment and settle-
ment opportunities. The healthcare system
of the UAE is particularly advanced, drawing
healthcare professionals from across the
globe. Remarkably, expatriates constitute
about 97% of the healthcare workforce,
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underscoring the linguistic and cultural diversity within
this sector.
The UAE and many surrounding Arabic countries have
healthcare systems in which the majority of staff are over-
seas practitioners; therefore, language barriers can pose
major challenges. For example, the medical and nursing
workforce in the UAE is diverse and practitioners have
differing cultural, linguistic, religious, socioeconomic,
clinical and educational backgrounds. Southeast Asia (ie,
the Philippines) and South Asia (ie, India) are the coun-
tries of origin for most medical and nursing staff, with
other common source countries including Australasia,
Europe and North America.2–4 These healthcare practi-
tioners speak various languages and dialects, whereas the
official language of the UAE and only language spoken
by the majority of the local population is Arabic. Because
of these language discrepancies, English is the language
used in the healthcare system.
In addition to this diversity among healthcare practi-
tioners, the UAE population (around 10 million people)
is diverse. UAE nationals comprise around 11.4% (ie,
1.16 million people) of the total population, with other
population groups being Indian (27.49%), Pakistani
(12.69%), Bangladeshi (7.40%), Filipino (5.56%),
Iranian (4.76%), Egyptian (4.23%), Nepali (3.17%), Sri
Lankan (3.17%), Chinese (2.11%) and other (17.94%).5
A significant proportion of this population, especially
UAE nationals and the Arab population, are not compe-
tent or literate in English, despite this being the main
language used in the healthcare system. Using the English
language mainly for communication in the healthcare
system has created gaps between healthcare practitioners
and patients. In addition to practitioner–patient commu-
nication issues, which affect the quality and safety of
services, the diversity in the UAE healthcare system has
contributed to other professional and educational prob-
lems; in exceptional situations (eg, the recent pandemic),
this threatened the stability and sustainability of health-
care services.2 6 Overall, this diversity has affected the
provision of comprehensive and culturally competent
healthcare for patients from different cultures, religions
and ethnicities.7
The literature shows that there is more to communica-
tion than merely speaking the same language. A previous
study noted that language barriers have cultural connota-
tions8 as language and culture work in parallel. Therefore,
both language and culture need to be considered when
discussing communication. It is sometimes believed that
healthcare providers can ‘learn as they work’ with patients
from other cultures. Although elements of this assumption
may be relatively true, there are dangers associated with this
simplistic attitude in the healthcare context, as it may result
in misunderstandings or mistakes (eg, misdiagnosis, violation
of patients’ beliefs) that have associated financial and other
costs.9 Culture-­based challenges identified in Arabic and
Muslim contexts include managing non-­verbal communica-
tion issues. For example, although many cultures use touch
as part of communication (eg, shaking hands), this contact
2 Al-­Yateem N, et al. BMJ Open 2023;13:e076326. doi:10.1136/bmjopen-2023-076326
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may not be appropriate in these contexts, especially between
men and women. These limitations in the use of non-­verbal
communication techniques may pose further challenges for
some healthcare practitioners, such as nurses, whose roles
include frequent patient encounters.7 10 11
Delivering high-­ quality healthcare services in a diverse
context requires multi-­ faceted cooperation. Research
suggests that poor patient outcomes and compliance
along with increased health disparities may result from
a lack of culturally competent care, irrespective of avail-
able services12 13 14. A pertinent example can be found in
a recent study by Al-­ Yateem et al (2023).15 The research
highlighted that communication barriers and past negative
experiences with healthcare professionals led some Emirati
parents to prefer using traditional and herbal remedies for
their children before seeking professional healthcare. This
preference, stemming from factors such as feeling rushed,
misdiagnoses or not being listened to, culminated in delays
in treatments and occasionally in untreatable complications.
Such challenges faced within the UAE healthcare system
reinforce the reliance of many parents on home remedies.
This underscores the significance of addressing communica-
tion barriers and ensuring culturally competent care in the
healthcare system to enhance the quality of services and user
experiences.
Previous studies indicated that medical providers with
poor cross-­ cultural communication skills had more job-­
related anxiety and dissatisfaction than those that had these
skills.169 It has also been reported that health professionals
tended to rely on bilingual colleagues or patients’ relatives
as interpreters to cope with language-­related communica-
tion barriers.17 18 However, given that the use of these casual
interpreters has previously been associated with several issues
(eg, miscommunication, poor quality care, confidentiality
problems), it may not offer a practical solution.19 A more
common practice in addressing language barriers in health-
care settings is to utilise professional interpreter services.
These trained individuals bridge the language gap and also
understand the nuances, cultural contexts and medical
terminologies, which ensure a more accurate and efficient
communication.20 21 Not incorporating such services where
needed can potentially compromise patient care and safety.
Furthermore, another study argued that discrepancies in
communication related to language may increase patients’
psychological stress and result in errors with medically signif-
icant consequences, whereas patients in language-­congruent
encounters do not have this exposure.22
In addition to unfamiliarity with the language and
culture23 highlighted a number of other factors that
contributed to poor intercultural communication in
the healthcare context, including patients being too
unwell or anxious to focus on communicating clearly,
providers being technology-­focused and time limitations.
It is important to note that language-­related communi-
cation problems impact both healthcare practitioners
and patients. Associated problems include miscommu-
nication around details of diagnoses, care/other instruc-
tions and treatment options, which may reduce patients’

adherence and increase their anxiety.17 The access of
patients to high-­quality and timely healthcare service may
be negatively affected,8 which influences their trust and
satisfaction from the services they receive.
Language-­ related communication problems between
healthcare professionals who does not speak Arabic and
their local patients are common in the UAE. Therefore,
we investigated language barriers encountered by health-
care practitioners when communicating with patients/
patients’ families in the absence of a shared language in
different healthcare contexts in the UAE. We explored
practitioners’ perceptions of the impact these language
barriers had on their daily practice as well as their sugges-
tions regarding potential solutions.
METHODS
Study design
This study used a qualitative exploratory phenomeno-
logical design. This design was considered appropriate
to answer our research questions about healthcare prac-
titioners’ experiences in relation to language-­ based
communication challenges and barriers encountered
during daily practice in healthcare settings in the UAE.
Study participants and setting
Participants in this study were expatriate healthcare
practitioners working in the UAE who were not fluent
in Arabic. The determination of their fluency in Arabic
was based on their self-­assessment rather than a formal
language proficiency test. We included participants with
various medical and nursing specialties from different
UAE healthcare institutions. Study participants were
diverse in terms of their years of work experience, had
experience working in different healthcare systems
and settings, and spoke different languages than their
patients.
We purposively selected a sample of volunteer partic-
ipants with diverse specialties from major hospitals in
different Emirates. This allowed us to capture differing
perspectives and insights from practitioners with varying
levels and types of work experience. After gaining
approval from the relevant hospitals, an email was sent
to healthcare staff in each hospital that included infor-
mation about this study and an invitation to participate.
The invitation emphasised the confidentiality of their
participation and the protection of their data. Inter-
ested participants responded to the email invitation, and
arrangements were made for their interviews.
Data collection
Data were collected through in-­ depth semi-­
structured
interviews. The interviews were conducted in English
language.
An interview guide was developed to guide the inter-
views and maximise the data collected (online supple-
mental file). The interview guide covered participants’
native language, other languages they spoke, field of
Al-­Yateem N, et al. BMJ Open 2023;13:e076326. doi:10.1136/bmjopen-2023-076326
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specialisation, years of experience in their respective
practice areas, overall professional experience (including
experience in their home country and other countries
in which they had practiced) and the duration of profes-
sional experience in the UAE. These initial questions
were followed by a general discussion about the diffi-
culties and challenges faced when communicating with
patients or patients’ relatives with whom they did not
share a common language (eg, English, the participant’s
native language or any other language). Probing ques-
tions were used to elicit details about the consequences
and effects of these challenges, coping strategies used
and effective approaches to address these challenges. In
addition, participants were asked about any support avail-
able to help them tackle this issue and recommendations
for future strategies that could be helpful.
Each interview lasted approximately 30–45 min and was
conducted at a location agreed on with the participants
to ensure their comfort and maximise the information
obtained. The interviews were recorded and then tran-
scribed for analysis. The recording method minimised the
impact on the quality of data obtained. To protect partic-
ipants’ privacy, all data, including participants’ interview
recordings, were anonymised and kept confidential, and
no details that could potentially reveal their identity or
workplace were reported. These considerations were
crucial for improving the quality of data obtained given
the sensitive nature of the topic, as participants shared
experiences and difficulties they had encountered while
caring for patients and families. This study included 14
healthcare practitioners. Data saturation was achieved
with this sample. The data was collected over a period of
3 months from January 2023 to March 2023.
Data analysis
The data collected in the in-­ depth interviews were
analysed using Van Manen’s selective or highlighting
approach, following the iterative process followed in the
hermeneutic circle. The process started with verbatim
transcriptions of the audio recordings, which allowed us
to grasp participants’ descriptions of their experiences
in their entirety. Each transcript was read multiple times
not only to foster familiarity with individual participant
narratives (the ‘parts’) but also to gain an overall under-
standing of the collective experiences (the ‘whole’).
Initial notes were recorded during these readings.
Drawing on the principles of the hermeneutic circle,
our understanding of individual statements was enriched
by our evolving comprehension of the overall narrative,
and vice versa. Throughout this process, we identified
statements or phrases that seemed ‘particularly essential
or revealing’ about the participant’s experiences.24 These
key statements, phrases or words were highlighted for
deeper examination.
Subsequent to this, initial descriptive coding was under-
taken. The highlighted portions were coded using partici-
pants’ own language, grounding our analysis in their lived
experiences. Codes with similar content were grouped
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iteratively and then were merged together and organised
into overarching themes.
One issue that is worth noting is the composition of the
research team; all research team members are fluent in
both Arabic and English. While some are native English
speakers with fluency in Arabic, others are native Arabic
speakers proficient in English. This linguistic diversity
enables the team to discern subtle meanings and emotions
in the data. Such diversity ensures a comprehensive and
varied interpretation of the data. The team consistently
discussed their findings to cover all data facets and mini-
mise any unintentional cultural or linguistic biases.
Research team
The study team comprised male and female researchers
with postgraduate qualifications. The team currently
worked in academic institutions but had previously held
clinical roles. All interviews were conducted by a female
research assistant who was master’s-­prepared and familiar
with the interviewing process. The team had no relation-
ships with the participants either before or at the time of
the interview. However, to facilitate information sharing
during the interviews, the interviewer took the time to
establish a relationship with participants and started each
interview with general questions to break the ice and
strengthen the relationship before moving to the specific
interview questions.
Ethical considerations
Healthcare practitioners who agreed to participate in this
study received an information sheet that outlined their
rights, including the right to withdraw from this study at
any time without giving a reason. Furthermore, partici-
pants were assured that their participation was anony-
mous and that the information provided would be kept
confidential and only used for this study. Participants
were asked to sign a written consent before conducting
the interview.
Patient and public involvement
None.
FINDINGS
The interviewed participants consisted of a diverse group
of medical and nursing practitioners from various coun-
tries, including India, Pakistan and America. They repre-
sented both the public and the private healthcare sectors
in the UAE. Approximately two-­thirds of the participants
were from the public sector, with the remainder from the
private sector. Their specialties included ophthalmology,
intensive care, anaesthesia, nephrology, critical care medi-
cine, obstetrics and gynaecology, paediatrics, urology and
internal medicine. Figure 1 provides a detailed break-
down of the participants’ characteristics.
The participants’ experience in the UAE varied,
ranging from less than a year to over two decades of
practice. For added context, while the public sector in
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the UAE dominates health services coverage, the private
sector also plays a significant role in service provision.
Regarding Arabic language proficiency, participants
self-­assessed and described their capabilities. While most
of the participants reported a basic understanding of
some Arabic words and phrases, only one self-­described
having an intermediate level of proficiency.
The analysis of the interview transcripts revealed three
main themes: Feeling left alone; Trying to come closer to
their patients and Feeling guilty, scared, and dissatisfied.
Feeling left alone
All participants noted that in their workplace, non-­Arabic-­
speaking medical practitioners were not offered formal
professional development to address language-­ related
communication challenges in their clinical work. Some
participants reported that they had faced similar chal-
lenges in their previous work in other Gulf Cooperation
Council countries.
There has never been formal training in the Arabic
language received. (P5)
No formal training in Arabic language received in all
the Gulf countries I worked in, including [the] UAE.
(P14)
Participants also reported their workplaces did not
have facilities for formal interpretation services, meaning
no professional medical interpreters were employed on
either a permanent or a temporary basis to facilitate
communication with patients. Many participants indi-
cated they tended to ask medical and other staff working
with them to do translation for them when necessary.
They described how this meant that they were often left
alone to cope during difficult situations.
I'll tell you from my experience in Bahrain, Saudi,
and Dubai. The only place where it was formally avail-
able was in Saudi in government hospitals; we have
a woman who sits there for translation. If three or
more doctors need her, then it becomes more diffi-
cult. But here in hospitals, I rely on the nursing girls
who speak Arabic and have a little time to come from
their work or duty. And if they are busy, we cannot ask
them to come. So, we use anybody from the nursing
girls to the receptionists. (P7)
Some participants indicated that they attempted to
address the language barrier in their clinical work by
relying on a mix of broken Arabic and English, along with
non-­verbal language techniques. This meant that they
could perform their clinical duties without requesting
translation assistance from colleagues. However, they
noted that this approach was not always easy and could
cause problems if an incorrect word or phrase was used
in a certain context or a word was not pronounced prop-
erly. At times, this could lead to even bigger issues. This
was further complicated by the many different Arabic
dialects; some words that participants used could be easily

Figure 1 Participants’ characteristics. aYears of experience refers to experience in the UAE.
understood by some Arabic patients but not by others
who used a different dialect.
Many times, I try to communicate with broken Arabic;
I do communicate. But it does not work sometimes.
I will end up in a bigger issue, saying the word again
and again until they understand it. This is frustrating
for me and for them. (P12)
Now, Emirati Arabic is what I am mostly used to.
Egyptian Arabic is sometimes difficult to understand
because the terms they use are slightly different from
what the Emirati use, and there are many other dia-
lects. (P9)
Those who are coming from Jordan, Syria, Iraq, their
dialect is slightly different from what Emirati speak.
(P9)
However, at times the use of broken Arabic was consid-
ered helpful, especially when words/phrases were
correct. Participants noted that many patients and their
families appeared to be more comfortable with this form
of communication and were receptive of the messages.
Many of them will be surprised when I say it in Arabic
words; they will like it and laugh, and they look more
engaged, even with the simple words that I use. (P13)
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Participants highlighted various differences between
the UAE and their home countries in terms of aspects
of the healthcare system (eg, increased use of computers
during patient encounters, which reduced actual time
spent interacting with patients). These differences could
sometimes increase the difficulty of their work as they
sought to focus on patient treatment. Many participants
highlighted that language barriers presented the most
significant challenge in their workplace and negatively
impacted their communication with Arabic-­ speaking
patients and the families. Participating healthcare profes-
sionals suggested that speaking directly to their patients
(ie, in Arabic) was an important consideration. They
noted that this would facilitate and enhance communica-
tion with their Arab patients.
Sometimes, we feel the language barriers come.
Because we can communicate with the patients more
if we know Arabic, but due to this, we feel more re-
stricted. (P2)
From my experience, there are three challenges; one
of them is the language, of course. (P4)
Participants reported that the communication problem
worsened when none of the patient’s family members
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present understood English. If at least one family
member could speak or understand English, healthcare
practitioner–patient communication was facilitated. This
language barrier often meant that participants felt unsatis-
fied with their performance because they were concerned
about not being able to convey complete messages and
proper treatment or care directions to their patients.
I find it difficult to communicate with them. And this
is where I worry. The challenges I would say I am not
very sure if I conveyed the message or not. (P7)
Some participants mentioned they had encountered
serious life-­or-­death matters that they felt could not be
ignored. In these situations, optimal communication was
required to avoid threats to life.
…there are two scenarios, what I will say: 1) If the
patient has an ectopic pregnancy or 2) the patient
has a small baby because they are two life-­threatening
things. One for the baby and one for the mother. I
have to make sure that the patients fully understand
the situation. Sometimes the idea that they did not
understand me scares me. (P7)
It was noted that such risky situations had potential to
negatively impact healthcare practitioners, especially if
a patients left the encounter without a sufficient under-
standing of the explanations and instructions they were
given. Some participants also noted that they preferred
to speak directly to their patients without a third party
present to provide translation, but this was not possible
without being fluent in Arabic.
I want to ensure that they understand my message.
They go with a little more than half a message. It
makes me feel a bit scared of how to communicate in
such a scenario. I have used nurses also, or nursing as-
sistants. But again, I feel I can do better if I can speak
directly to them. (P7)
Feeling insufficient: Trying to come closer
Participants believed that healthcare practitioners
working in the UAE should at least try to acquire basic
terms in the local Arabic language to better commu-
nicate with their only Arabic-­speaking patients. Some
participants noted that patients often demanded
detailed information in Arabic, which could cause addi-
tional stress and challenges. This was noted as a major
issue during a patient’s first visit to the clinic when
communication was particularly challenging as health-
care professionals lacked sufficient information about
their health status.
Patients are looking for details; they have lots of ques-
tions. If the patient is diagnosed with diabetes and
if I have to treat them by giving them injections in
the eye or I have to give them laser…there is a lot of
information that needs to be given to patients. (P1)
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Some participants noted that communication in a
patient’s native language was required to help them stay
calm and offer counselling.
It is difficult with patients who are very anxious about
it, and if I have to calm them down or counsel them,
then it gets very difficult. (P1)
Another challenge related to insufficient language
skills was communicating with patients about critical
health issues (eg, kidney failure), where detailed infor-
mation needed to be exchanged.
I know that sometimes patients are very sensitive.
In our field, with kidney failure cases, it is very diffi-
cult, like breaking bad news. I say to my patient you
require daily dialysis; I use very superficial broken
Arabic terms for that. (P3)
Furthermore, participants suggested that healthcare
practitioners needed to appreciate the importance of
learning the local language, especially when this allows to
provide a better quality and safer care for their patients.
Language is very important, especially for us Indians.
We know the value of a language, as India has lots of
languages. If I know one language I can speak, then
I can speak to 1–100 million people who speak this
particular language. (P3)
In addition, participants highlighted that learning at
least some of their patients’ native language always made
a difference when attempting to establish relationships
with patients.
So, to know something is better than to know noth-
ing…the language is very important, especially with
locals. It makes a difference if you know how to speak
some languages…You will build trust and satisfaction,
especially since we are dealing with human beings.
(P3)
An important point raised by participants was that the
language barrier and associated communication prob-
lems had a serious impact on them as healthcare prac-
titioners. It was noted that this issue could result in lost
confidence in performing their job.
Initially, it was…a’ah…Communication was very diffi-
cult because I don’t know any Arabic and here, they
speak mainly Arabic. So, it was really a problem, and
I was frightened to go to the office. And I don’t know
what I will face sometimes if I am called. I don’t know
what they will give me. (P11)
Many participants offered examples of situations that
highlighted the importance of proper communication
with patients in clinical environment, especially as they
often needed to exchange complex information about
patients’ medical history, diagnosis and care. Several
participants shared details of challenges they had expe-
rienced because of the lack of professional interpreters
in their workplace. Participants also noted that in some

cases, it was preferable for the interpreter to be a doctor
to ensure important information was properly conveyed.
We need interpreters for the families who do not
know any English. Even if they know some English, I
prefer to use interpreters because there is some tech-
nical stuff to be translated. It’s better to have inter-
preters, which I prefer to be medical doctors, as they
know all the medical terms; even nurses and health-
care staff will not be able to express certain medical
issues. (P6)
Patient–clinician communication in the first encounter
was noted to be more complicated than communication
in subsequent visits or with patients who had visited the
clinic frequently and could understand (at least partially)
some terms and instructions used. Patients’ attitudes
were noted as sometimes making communication more
difficult, as uncooperative patients were considered more
challenging to communicate with.
Patients are looking for details, and they have lots of
questions. Added to that, communication gets diffi-
cult if the patient is not cooperative with the doctor
and has lots of stress and fears. As a result, the doctor
requires a good bank of terms and phrases in Arabic
to enable him/her to handle such difficult situations.
(P1)
Participants indicated that cultural differences could
also complicate communication, as healthcare practi-
tioners needed to be familiar with the culture as well as
knowing the local language. Becoming familiar with and
accepting other cultures was considered an important
additional task that must be undertaken.
Settling down is important for medical practitioners
who come to work in another country to show better
professional performance. In addition to language is-
sues, there is the culture. Language and culture often
go hand in hand in many scenarios and situations.
They seem to be complementary. (P6)
Feeling guilty, scared, and dissatisfied
Participants reported that struggling to communicate
effectively and accurately share important information
with Arab patients often left them feeling frustrated and
dissatisfied.
So bad we feel sometimes. Otherwise, we do not face
any professional issues with this. But for our satisfac-
tion, we feel it is good to speak the patient’s language.
(P2)
In addition, participants’ narratives suggested that
worry about not being able to accurately communicate
essential information regarding patients’ health condi-
tions and treatment could have various negative impacts,
both at the psychological and professional domains.
The challenge, I would say, is that I am not very sure
if I conveyed the message or not. (P7)
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It was also highlighted that participants encountered
cases that concerned serious matters that could not be
ignored. These cases required urgent and timely solu-
tions, especially given the potential for negative conse-
quences for both patients and healthcare practitioners
if a patient left the clinic without clearly understanding
important messages related to their health condition and
treatment.
These are some of the potential risks that could occur
as a result of the language communication barrier,
and that is a scary matter! I want to ensure that they
understand my message. They go with a little more
than half a message. It makes me feel scared about
how to communicate with such a scenario; I have
used nurses also, but nurses or nursing assistants. But
again, I feel I can do better if I can speak directly to
them. (P8)
Participants sought to treat their patients as whole indi-
viduals and address both physical and emotional needs.
However, when language-­based communication barriers
existed, important information for patients may not be
conveyed accurately.
Not just you do want to be in trouble. It’s not just
a doctor trying to save a patient’s life. You want to
express the importance, but not being able to…The
message is not conveyed. (P10)
Participants stated that being unable to ensure that
important healthcare messages were properly commu-
nicated to and understood by their patients gave rise
to concerns and fears about potential negative conse-
quences (psychological and professional).
Yeah, and you worry that this patient is not listening,
and they could come back with a bigger problem.
(P14)
Several participants gave examples of the impact of
language barriers on effective communication based on
their past experiences in similar countries and contexts.
Understanding the local language would help them to
communicate more effectively with patients but would
also offer some protection from potential risks.
Like when I first came to Saudi Arabia, I went to
Jeddah first, then from Jeddah to Dammam. Then,
there was my passport stamping. I actually came to
Saudi during Ramadan; it was the first day of Ramadan
and I was not able to receive my passport from the
first day I arrived. Somebody told me: go, go, go, and
others said: come, come, come. Something like: He
did not know English and I didn’t know Arabic. He
wanted to take me to the Airport in Dammam, a par-
ticular airport, but he couldn’t understand me, and I
didn’t understand him. And he went to the comput-
er and I said, why? He said something, he wanted to
deport me. Yes, scary, sometimes misunderstanding
communication becomes very difficult. (P12)
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Participants expressed that reliance on help with
patient communication from Arabic-­ speaking coun-
terparts introduced a risk for various communication
errors, potentially leading to patients missing important
healthcare messages and instructions. As a consequence,
negative outcomes may arise that adversely impact both
parties. Healthcare practitioners may be blamed for not
the consequences of language-­ related communication
problems, such as provision of insufficient details about
diagnoses and treatment and medical decisions based on
incomplete information. In some cases, such issues could
have legal ramifications.
…Yes, we rely a lot on interpreters from co-­workers,
etc., but is that correct? Is it appropriate? Is the mes-
sage being conveyed properly? Is it what we want to
say? We don’t know, we are not sure. What if it was
not accurate? What if they told me something not
correct? I will make a wrong decision based on that. I
don’t know. (P5)
DISCUSSION
This study investigated challenges associated with
language barriers for healthcare practitioners working in
diverse healthcare contexts in the UAE. All participants
had experienced language barriers in their encounters
with patients or patients’ family members, as they spoke
no Arabic or only knew some Arabic words/phrases.
Our findings suggested that language barriers negatively
impacted healthcare practitioners’ daily clinical practice.
Participants reported sometimes feeling guilty, scared and
dissatisfied because of their inability to convey medical
information accurately because of the language barrier.
Social identity theory (SIT) suggests that healthcare prac-
titioners derive a sense of identity and self-­esteem from
their professional group with a shared language and
culture. When they cannot effectively communicate with
patients or their families because of language barriers,
they may feel inadequate and experience dissonance in
their professional identity.25
These negative impacts on healthcare practitioners’
self-­
concept and self-­ esteem can have severe conse-
quences, including life-­ threatening misunderstandings,
adverse psychological effects and various professional
impacts. Therefore, comprehensive efforts are required to
improve health equity by addressing language barriers.26
Participants in this study recommended using profes-
sional medical interpreters to overcome language barriers
in the healthcare context. However, it is essential to note
that effective collaboration with interpreters is a skill that
needs to be learnt and developed by healthcare practi-
tioners.27 This highlights the importance of having access
to interpreters and understanding how to effectively work
with them to ensure accurate communication and under-
standing between healthcare practitioners and patients
who do not speak a shared language.18 28 A previous
study found that using professional interpreters who
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were present at the location was a frequently suggested
solution for overcoming language barriers in healthcare
settings.27–29 However, the use of professional interpreters
may vary by the type of healthcare professional and clin-
ical situation.27 29
Participants occasionally relied on patients’ family
members or bilingual staff as interpreters, even though
they may lack proficiency in medical terminology, poten-
tially side-­lining professional interpreters.29 30 Using ad
hoc interpreters may be detrimental to effective health-
care practitioner–patient communication and should not
be considered a replacement for professional interpreters
in healthcare settings. Another critical aspect brought to
the fore is the occasional dependence on patients’ family
members, including children, to serve as interpreters.
This approach, while seemingly convenient, poses a risk
of compromising the patient’s confidentiality and inhib-
iting the open discussion of sensitive or private matters.
Relying on ad hoc or family members interpreters, espe-
cially those without proficiency in medical terminology,
can lead to inaccuracies in translation and potential
miscommunications. Moreover, patients might withhold
critical information or fail to ask important questions
due to discomfort or fear of judgement from their family
members. Thus, while family involvement can be bene-
ficial in various aspects of patient care, serving as inter-
preters may not be the optimal role for them, particularly
when discussing sensitive topics. Comprehensive profes-
sional interpretation services, familiar with both medical
terminology and the nuances of patient privacy, remain
paramount.
The UAE government recognises the significance of
overcoming language barriers in healthcare. Existing
guidelines advocate for the use of professional inter-
preters, emphasising their importance in ensuring
accurate and efficient communication. However, gaps
persist, around coverage and availability, also in relation
to training healthcare practitioners in maximising the
benefits of working with interpreters. Observing health
systems from countries with significant immigrant or
minority populations, such as Canada or Australia, reveals
a more structured approach to integrating interpreters
into the healthcare process, ensuring inclusivity and
understanding.
Participants in this study believed that healthcare profes-
sionals should be proactive in learning basic medical
terms in Arabic to ensure they could communicate with
their patients in their native language. In the global
healthcare landscape, cultural sensitivity is paramount,
particularly given the mosaic of nationalities present in
settings like the UAE. Specifically focusing on the Arab
population, which serves as a case exemplar, it is clear
that linguistic competence goes together with cultural
understanding. Arabic-­speaking patients might not only
come with linguistic preferences but also unique cultural
beliefs regarding healthcare, family dynamics and doctor–
patient relationships. Addressing language barriers
without accounting for these cultural nuances may only

partly bridge the communication gap. This aligns with
the self-­categorisation process described in SIT, whereby
individuals categorise themselves into a group and align
their behaviour with the norms and expectations of
that group.31 Learning basic medical terms in the local
language allows healthcare practitioners to demonstrate
their affiliation with the cultural group of their patients,
which can increase patient trust and satisfaction. This was
consistent with a study that showed providing care in a
patient’s primary language improved communication,
built trust and enhanced the quality of care.32 Therefore,
learning basic medical terms in patients’ native language
offers an innovative and effective solution to address the
language barrier issue and improve healthcare services
for Arab patients.
Our participants indicated that the ability to commu-
nicate with patients in their local language was necessary
to help patients become calm and provide counsel-
ling. Effective communication in a patient’s preferred
language improved patient satisfaction and perceptions
of care quality. Effective communication is also crucial
for building trust and establishing a positive relationship
between healthcare providers and patients.8 10–13 Partici-
pants highlighted the need for healthcare practitioners
to be familiar with their Arab patients’ culture. This was
consistent with previous studies that emphasised the
need for healthcare providers to be culturally compe-
tent.10 11 15 25 31 33
Concerns associated with being unable to accu-
rately convey medical messages to patients may nega-
tively impact healthcare practitioners psychologically
and professionally. This fear is consistent with a social
identity threat, whereby individuals perceive that their
social identity is threatened when they face situations
that compromise their ability to perform effectively.25 31
Previous studies also reported that language barriers had
a negative impact on psychological well-­being and job
satisfaction among healthcare providers.34 In particular,
poor communication can affect the delivery of quality
care, potentially leading to poor patient outcomes, lost
resources and increased costs to the healthcare facility.1
Failures in communication may also negatively affect
patient and staff satisfaction.35 Cultural differences
mean that language-­ related communication barriers
may be compounded by some aspects of communica-
tion (eg, use of abrupt language, too much or too little
eye contact, rushed explanations), which negatively
influence patients’ experiences. Therefore, providing
specific communication training for healthcare practi-
tioners may contribute to improved patient outcomes
and satisfaction.
Language barriers can have major impacts on health-
care delivery, patient safety and satisfaction. Compre-
hensive efforts are required to improve health equity by
addressing these challenges, including using professional
interpreters, educating staff on effective communica-
tion and familiarising themselves with patients’ cultural
differences. Addressing language barriers is crucial for
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providing quality healthcare services, building trust and
rapport with patients, and improving patient outcomes.
Conclusions and recommendations
This research underscores the profound influence of
language barriers on healthcare in the UAE, impacting
patient safety, the quality of care and the well-­being of
healthcare practitioners. Comprehensive strategies are
essential for advancing health equity in light of the iden-
tified challenges.
The integration of professional interpreters into health-
care settings stands out as a critical solution to bridge the
language gap. Moreover, it is vital for healthcare profes-
sionals to be equipped with the skills necessary to collab-
orate effectively with these interpreters. Another vital
aspect is the encouragement for healthcare practitioners
to learn basic medical terminology in Arabic, which can
foster improved communication with Arab patients and
enhance the overall care experience. Beyond language,
gaining an understanding of the Arab culture is impera-
tive for healthcare practitioners. This cultural familiarity
can amplify the depth and effectiveness of patient interac-
tions, ensuring that care is both comprehensive and sensi-
tive to patients’ backgrounds.
The implications of this study extend to various stake-
holders. Policymakers can utilise our findings to craft
more informed healthcare policies, ensuring effective
communication in diverse settings. Corporate entities
might consider introducing specialised training modules
to equip their staff with the necessary linguistic and
cultural skills. On the hospital administration front, there
is an urgency to ensure that professional interpreters are
accessible, fostering seamless communication between
patients and practitioners.
Future research directions could encompass exploring
the perspectives of Arabic-­ speaking patients. Such an
endeavour would provide deeper insights into the chal-
lenges of linguistic communication in the healthcare
context. In conclusion, addressing the interplay of
linguistic and cultural nuances is crucial in healthcare.
Such considerations are pivotal for enhancing the quality
of care, building trust and ensuring optimal patient
outcomes.
Study limitations
This study has several limitations that should be consid-
ered when interpreting the findings. First, the study relied
on participants’ self-­assessment of their Arabic language
proficiency rather than conducting a formal language
proficiency test. Self-­assessment can be prone to biases,
with individuals potentially underestimating or overesti-
mating their abilities.
Additionally, participants were asked to share their
experiences and difficulties encountered during their
professional practices. Given that admitting linguistic or
professional shortcomings might be perceived as having
implications on their career, there could be a hesitancy
among some participants to fully disclose or elaborate on
9
 Open access
certain challenges. This could lead to potential under-­
reporting or selective sharing of experiences.
The study’s recruitment strategy, which purposively
selected participants from major hospitals in different
Emirates to gain diverse insights, might have inadver-
tently excluded experiences of healthcare practitioners
from smaller or rural healthcare settings. This could
potentially limit the generalisability of the findings.
Another point to consider is the potential influence of
the interview recording. While steps were taken to ensure
rapport-­building and create comfortable environments
for the participants, the presence of the recording device,
even though intended to ensure data accuracy, might
have made some participants more cautious or restrained
in their responses.
Finally, while our study provides valuable insights into
the perspectives and experiences of healthcare profes-
sionals, it is important to acknowledge the intrinsic nature
of communication as a two-­way process. The absence of
patient perspectives in our research presents a significant
limitation, as their insights could have further enriched
our understanding of the communication challenges
faced in healthcare settings. The missed opportunity to
capture patient experiences may have potentially limited
the comprehensiveness of our findings.
Author affiliations
1 6 Al-­Yateem N, Al-­Marzouqi A, Dias J, et al. Leadership for professional
College of Health Sciences, University of Sharjah, Sharjah, UAE
2 advancement and evidence-­based practice in UAE: now more than
Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
3
Faculty of Nursing, Applied Science Private University, Amman, Jordan
4
Sheikh Shakhbout Medical City, Abu Dabi, UAE
5
School of management, Universiti Sains Malaysia, Penang, Malaysia
6
Georgetown University, Washington, District of Columbia, USA
7 8 Gregg J, Saha S. Communicative competence: A framework
Critical Care and Emergency Nursing Department, Faculty of Nursing, Alexandria
University, Alexandria, Egypt
Contributors NA-­Y conceptualised and designed the study, supervised the
research team, wrote the manuscript and provided critical revisions. HH conducted
the primary experiments, analysed the initial data and contributed to writing
the methods section. AS assisted in study design, managed data collection and
contributed to the discussion section. RM conducted literature review, contributed
to the manuscript’s background and provided technical support during experiments.
IR assisted in data analysis, interpreted results and contributed to the results
section of the manuscript. SAR managed participant recruitment, contributed to
the methodology section and assisted in data interpretation. MS provided logistical
support, managed resources and contributed to the manuscript’s supplementary
materials. FRA assisted in drafting the manuscript, provided critical feedback and
contributed to the final editing and proofreading. All authors read and approved the
final manuscript. NAY is the guarantor of this work.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not applicable.
Ethics approval This study involves human participants and was approved by
Institutional Review Board of the University of Sharjah (Ref # REC-­21-­04-­08-­01-­S).
Participants gave informed consent to participate in the study before taking part.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request.
Anonymised interviews transcripts can be made available upon reasonable request
made to the corresponding author.
10
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Supplemental material This content has been supplied by the author(s). It has
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peer-­reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iDs
Nabeel Al-­Yateem http://orcid.org/0000-0001-5355-8639
Fatma Refaat Ahmed http://orcid.org/0000-0002-1008-8216
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