1Faculty of Languages and Linguistics, University Malaya, 50603 Kuala Lumpur, Malaysia
2Centre of Language Studies, UCSI University, 56000 Kuala Lumpur, Malaysia
*Correspondence Author’s Email: adityakaruthan@gmail.com
Keywords: Communication Accommodation Theory; Medical Interaction; Nurse-Patients Interaction; Sociolinguistics
Nurses are fundamental to patient care in healthcare settings like hospitals and clinics. Effective communication with their patients and colleagues, including doctors, pharmacists, and technicians, is essential for the nurses (Hull, 2016). The nurses' job includes interacting with patients to collect medical information such as medical history, allergies, previous treatments, and surgeries (Swanson et al., 2020). In addition, nurses are required to oversee patients by providing first aid and medical care, reporting the patient's health, conducting medical tests and assessments, giving clinical judgement to the doctors, and providing appropriate treatment to the patients based on the doctor's instructions (NMBA, 2021). Nurses should educate patients about medical care both during admission and after discharge, including proper nutrition, physical activity, and post-treatment management.
Nurses also provide information and emotional support for their patients and families (Kullberg et al., 2015). This support helps nurses develop a relationship of trust with their patients (Hull, 2016). A strong rapport between nurses and patients enhances understanding of medical conditions and improves the quality of care. Effective nurse-patient communication is essential to delivering high-quality patient care, service, safety, and prevention of medical mistreatment (Brouwer et al., 2020).
Miscommunication and common breakdowns in communication, such as inadequate informed consent, miscommunication of important information on a patient's symptoms or condition, and poor documentation of patient history, can increase stress, anxiety, and dissatisfaction; at its worst, it can be life-threatening for the patients (Hewett, Watson & Gallois, 2015). In addition, medical mishaps due to miscommunication, misdiagnosis, and mistreatment can result in lawsuits where nurses are often blamed (NMBA, 2021). Furthermore, miscommunication among nurses and patients might compromise the quality of health care delivered (Mandal, Basu & De, 2020), especially when nurses and patients do not share a common language, such as English.
This study examines the communication difficulties experienced by Malaysian nurses who use English as a Second or Foreign Language (ESL/EFL) when engaging with foreign English- speaking patients in medical tourism hospitals in Malaysia. Additionally, it explores the language barriers these nurses face and the strategies they employ to adapt and improve communication within a multilingual healthcare environment.
English is an international language of medicine. Its significance is highlighted in International Medical Programmes (IMPs), where English is used for teaching, learning, assessments, and curriculum development (Chan, Mamat & Nadarajah, 2022). In Malaysia, English is the medium of instruction and learning in medical schools, while medical texts and journals are in English (Atefi et al., 2014). Therefore, medical practitioners, including nurses, must communicate well in English. Working with foreign patients and other healthcare professionals and communicating well in English are expected to provide efficient and excellent services (Forsgren et al., 2016).
With globalisation, there is a dire need to communicate in English, which is the international medical language (Hull, 2016). People from diverse cultures and languages cross borders to cquire medical and surgical treatment at a cheaper and affordable price and faster treatment, as their home countries may have a long waiting list (Fetscherin & Stephano, 2016). Malaysia is one of Asia's most popular destinations for medical tourists (Musa et al., 2012) because its cutting-edge medical facilities offer modern, specialised tertiary care (Aman, 2022). Furthermore, medical tourists are drawn to Malaysia due to healthcare workers' proficient use of English in communication (Aman, 2022).
This study investigates the English language communication challenges of Malaysian ESL/EFL nurses and their accommodation strategies while communicating with foreign English-speaking patients at a Malaysian Medical Tourism-Oriented Hospital (MTOH). Effective communication is crucial for quality care, services, and patient safety. Studies have shown that patients perceive nurses with limited English proficiency as less efficient and competent in their nursing duties (Tideman & Tengelin, 2019), leading to low satisfaction with the quality of healthcare delivery and patient safety (Musa et al., 2012). Other studies have indicated that patients were dissatisfied with their healthcare providers and unwilling to cooperate with the nurse when the nurses could not communicate effectively in English (Chan, Mamat & Nadarajah, 2022). The unwillingness of patients to share their concerns and the inability of nurses to pick up cues will lead to poor service and care.
Determining the language communicative challenges and accommodating strategies leads to pedagogical implications, such as early corrective actions that rectify the weaknesses so the nurses can communicate more effectively in clinical settings. This study aims to generate findings that contribute to communication training by incorporating insights from nurses for both local and international patients. Achieving this requires a comprehensive understanding of the lived experiences in nurse-patient communication.
The results of this study will further enrich the existing body of research on Communication Accommodation Theory (CAT), particularly within the context of medical interactions involving ESL/EFL nurses and English-speaking patients in Malaysia's multilingual healthcare environment. Given the increasing significance of effective cross-linguistic communication in healthcare, this study is both relevant and timely.
Recent research on interactions between healthcare providers and patients has gained significant attention, as stakeholders have recognised that language barriers between providers and patients who do not share the same first language may negatively impact the quality of healthcare services (Meuter et al., 2015). However, one of the main criticisms of second language communication research is the need for a solid theoretical foundation (McGilton et al., 2006).
Prior research on communication between nurses and patients has shown how important language competency is to providing quality healthcare. McGilton et al. (2006) reported that patients experienced increased anxiety and dissatisfaction when healthcare professionals faced difficulties communicating in a second language. According to Meuter et al. (2015), there is a greater chance of misunderstandings, and patient safety may be jeopardised when nurses and patients do not speak the same language. While previous studies have explored language barriers in healthcare, research remains limited on how specific communication accommodation techniques mitigate these challenges, particularly in multilingual medical tourism hospitals. Understanding these strategies is crucial to improving patient satisfaction and clinical outcomes. This study aims to fill this knowledge gap by investigating how Malaysian nurses modify their communication style to accommodate patients who speak English as a second language.
The theoretical framework used in this study is the Communication Accommodation Theory (CAT) developed by Howard Giles in the 1970s. CAT is a theory that explains how and why an individual chooses—or does not choose—to adjust their communication behaviour in an interaction (Denes, Gasiorek & Giles, 2016). This framework enables us to understand how people adapt, adjust, and accommodate their verbal and nonverbal communication to manage comprehension and social distance (Dragojevic, Gasiorek & Giles, 2016). This theoretical approach is relevant for comparing language-discrepant and language-congruent communication (Meuter et al., 2015).
CAT is an interactional approach, as it explains how and why specific interactions between people are successful and why some are not (Giles, 2016). CAT studies how people change their communication style during an interaction to either converge (make changes for better communication) or diverge (make modifications to show the difference in the communication) (Giles & Powesland, 1975).
This theory is suitable for studying people who do not share any common language and can only interact in one language or with people who speak a common language. For example, when one speaker speaks in their dominant language while the other is less proficient in the same language, or both speak in their second or foreign language (Hewett, Watson & Gallois, 2015). This theory is also applicable when individuals from diverse social groups, socioeconomic classes, and cultural backgrounds interact (Zhao, 2023; Lukitasari, Wulandani & Putra, 2024).
Miscommunication refers to challenges or difficulties in effectively conveying messages, intentions, beliefs, values, interests, or purposes during an interaction (Gasiorek & Giles, 2013). When people interact with each other, their vocal or non-vocal response differs from person to person. When people react negatively to a message, this is a form of miscommunication (Giles, Edwards & Walther, 2023) or conflict in the interaction between two or more people (Gasiorek & Giles, 2013). A smooth, accommodating interaction can only be successful if the speaker and listener change their communication behaviours to be cohesive and conflict-free (Giles, 2016). However, speakers also cannot change their speech behaviours during the interaction process, and this non-adjustment leads to non-accommodation (Chinna & Karuthan, 2020).
According to Giles, Edwars and Walther (2023), CAT significantly impacts a wide range of applied social situations, social groups, languages, cultures, and other aspects of communication. Barón-Birchenall (2023) asserts that CAT provides the most thorough framework for comprehending the interconnections, capabilities, and architecture underlying linguistic accommodation. Using Communication Accommodation Theory (CAT) as their theoretical framework, Minoo and Zahra (2023) examined how university students who are non-native English speakers adjust the level of politeness in their response emails to align with the tone used by an American correspondent. Their findings showed that non-native English speakers typically do not conform to the emails' verbal or structural politeness indicators. To learn more about non-native-accented speakers' communicative experiences with native German speakers, Petrou and Dragojevic (2024) conducted semi-structured interviews with these speakers using CAT. The participants reported both accommodation and non- accommodation, although underaccommodation was more common. Using CAT, Barlow et al. (2023) looked at how speaker qualities and communication behaviour affect how a "speaking- up" message is received in a medical setting. According to them, distinct therapeutic specialities had differing interpretations and responses to identical signals, with accommodating messages typically causing less discomfort than non-accommodative ones.
CAT research on patient and nurse communication provides valuable information on the effectiveness of communication. The researcher can investigate the relationship between the nurses and the patients, as the nurses spend more time with the patients than the doctors (Giles, 2016). Effective communication between nurses and patients is based on the nurses' and patients' ability to accommodate each other (Barlow et al., 2023). A positive nurse-patient relationship leads to patient satisfaction and lowers the possibility of medical errors (Farzadnia & Giles, 2015; NMBA, 2021). Ineffective communication within the medical ward occurs when nurses engage in patient categorisation or stereotyping (Jones, Woodhouse & Rowe, 2007) and are subjected to verbal abuse or inappropriate language from patients (Fatahi et al., 2010). A multinational study in Australian and Canadian hospitals mentioned that patients were dissatisfied with the medical consultations, as they were one-sided and non-accommodative (Baker & Watson, 2015). Another study revealed that nurses who communicated directly with patients, verified their understanding, solicited their opinions, and treated each other as equals during conversations were deemed accommodating (Jones, Woodhouse & Rowe, 2007).
Another study in Malaysia found that nurses frequently used convergent strategies, such as speaking slowly and using simple language, to accommodate foreign English-speaking patients. However, nurses seemed to apply more unnatural convergent strategies with the patient due to the nature of their work and to maintain the positive image of the medical institution. (Karuthan et al., 2020). Hence, the nurses practised "Forced convergence," where a person from a lower position had to adjust their communication behaviour to cater to those in a higher position (Giles, 2016). Older, native speakers happily accommodated their communication behaviours when interacting with Malaysian nurses. However, some younger native patients exhibited non-accommodative behaviour, highlighting the need for mutual adjustment in communication (Karuthan et al., 2020). The older patients were considered mature speakers, as they knew their surroundings and were able to change their communication behaviours (Ishak & Rafik-Galea, 2015).
The Malaysian nurses used the Malay slang "lah" in their patient interactions. Many of the older patients also used the same slang as the nurses as a gesture of goodwill to amuse the nurses and make them comfortable with them. When a foreigner incorporates slang into their speech, they aim to foster a sense of inclusion and minimise the social gap between themselves and their conversation partners (Dragojevic, Gasiorek & Giles, 2016).
This study employed a quantitative research design to gather information from nurses efficiently and cost-effectively (Creswell & Creswell, 2022).
The study population comprised Malaysian English as a Foreign Language (EFL)/English as a Second Language (ESL) nurses working at a Medical Tourism-Oriented Hospital (MTOH) in Kuala Lumpur, Malaysia. Participants included all Malaysian nurses, including matrons and sisters, who had been employed at the hospital for more than six months and held at least a diploma level of education. Ethical permission to conduct this study was obtained from the Medical Research and Ethics Community (MREC) under the Malaysian Ministry of Health Malaysia and from the University Malaya Medical Centre Medical Research Ethical Community (UMMC MREC).
A questionnaire was developed by adapting questions from Sachdev, Giles and Pauwels (2012) and Dragojevic, Gasiorek and Giles (2016), and further insights were incorporated from initial exploratory interviews with nurses and nursing tutors—the questionnaire aimed to assess the English language challenges faced by the nurses and their communication accommodation strategies. Three months before the study's duration, the questionnaire was pilot tested with one hundred nursing students at the university where the researcher worked.
The nurses were presented with a list of potential English language challenges derived from CAT medical interaction studies. The challenges are:
C1. Conveying messages in English
C2. Comprehending the patient's rapidly spoken English C3. Voicing out in English
C4. Understanding the patient's English pronunciation C5. Understanding their request in English
C6. Understanding the words spoken in English C7. Initiating the conversation in English
C8. Understanding English accents/slang wordsType equation here.
C9. Mixing up the English tenses
C10. Taking a long time to explain something in English
C11. Not knowing how to express myself appropriately in English C12. Tending to mix English and other languages
C13. Tending to use a lot of direct translations from my mother tongue C14. Take time to think in your mother tongue before replying in English
C15. Using Malaysian English particles (LAH, MAH) in English conversation C16. Using speech fillers (uh, ah, like, err)
C17. Feeling nervous while communicating in English
The nurses were provided with common communication accommodation strategies and examples, such as:
S1. Using a lot of hand gestures and non-verbal gestures
S2. Changing speech patterns (pronunciation/accent/slang/words) S3. Speaking louder
S4. Changing the speed of speech
S5. Making small conversations (small talk) S6. Mixing English and other languages
S7. Showing printed images or videos
S8. Presenting in a written format, either on paper or a phone S9. Getting another friend to help
S10. Repeating the words used/asking them to repeat their words
The nurses were provided with examples of how to respond to questions regarding their strategies in various scenarios. For instance, if a nurse faced difficulties in conveying messages in English, they would select the strategies they employed, with the option to choose multiple strategies. However, if the nurse did not experience challenges in conveying messages in English, they would proceed to the next identified challenge.
The questionnaire was administered online to all the Malaysian nurses working at the hospital from 1st to 17th March 2019.
The data from the questionnaire survey were analysed using IBM Statistical Packages for Social Sciences Version 24. Demographic characteristics, language proficiency, language challenges, and accommodation strategies were described as frequencies and percentages.
Those willing to participate had to sign a consent form and were assured of information confidentiality. The participants were informed that they could withdraw from this study at any time if they wished to, and their information would be kept confidential.
The present study received Ethical Approval from the National Medical Research Registrar (NMRR) with reference number 17-3415-39200 (IR), and the UMMC MREC with reference number 2018119-5975. The approved study duration was from 2nd August 2018 to 23rd July 2020.
A total of 432 nurses responded to the questionnaire. Table 1 presents the demographic profile of the respondents. Most study respondents were females (76.9%) aged 20-23 (75.4%), had a degree-level education (72.6%) and worked at the hospital for a year (84.8%). A total of 391 nurses, accounting for 90.5%, engaged in code-switching when communicating with family members or friends.
Table 1: Demographic Profile of the Respondents
Variable | n (%) |
Gender | |
Male | 78(23.1) |
Female | 354(76.9) |
Age | |
20-23 years old | 258(75.4) |
24-27 years old | 109 (20.2) |
28 & above | 65(4.4) |
Highest Education | |
Postgraduate | 10(2.55) |
Degree | 240(72.6) |
Professional Certificate | 16(1.9) |
Diploma | 166(23.1) |
Working Experience | |
One year | 222(84.8) |
2-3 years | 110(28.7) |
4-7 years | 61(3.4) |
More than eight years | 39(3.1) |
According to Table 1, most of the respondents were females (76.9%), aged 20 to 23 (75.4%), had a degree-level education (72.6%), and worked at the hospital for a year (84.8%).
The nurses were requested to specify their mother tongue or the native language and the languages they speak. The results are summarised in Table 2. Most nurses (91.3%) mentioned that their mother tongue was Malay, while the second language was English (92.5%). Most respondents (97.8%) spoke to their family members in Malay, and 82.2% spoke in Malay to their friends at the hospital.
Table 2: Mother Tongue and Languages Spoken by the Nurses in the Study
Language | Mother Tongue n (%) | Second Language n (%) | Languages Spoken with Family Members n (%) | Languages Spoken with Friends in The Hospital n (%) |
Malay | 396(91.3) | 21(4.7) | 414 (97.8) | 355(82.2%) |
Mandarin | 4(0.6) | 2(0.3) | 11(2.2) | 13(3.0%) |
Tamil | 11(2.2) | 4(0.3) | 6(1.2) | 5(1.2%) |
English | 11(3.1) | 399(92.5) | 151(45.8) | 53(12.3%) |
Iban | 5(1.6) | - | - | - |
Other | 5(1.2) | 8(2.1) | 22(6.5) | 6(1.4%) |
The nurses in the study were asked to state the languages they used for writing, listening, reading, and speaking at the workplace. Table 3 indicates that 74.5% of nurses wrote in English, while 69.9% read in English. In contrast, the majority preferred Malay for listening (65.7%) and speaking (71.5%).
Table 3: Languages Utilized by Nurses for Four Key Language Skills in The Workplace
Language | Writing | Listening | Reading | Speaking |
Malay | 110(25.5%) | 284(65.7%) | 130(30.1%) | 309(71.5%) |
English | 322(74.5%) | 135(31.3%) | 302(69.9%) | 115(26.6%) |
Mandarin | - | 13(3.0%) | - | 2(0.5%) |
Iban | - | - | - | 4(0.9%) |
Tamil | - | - | - | 2(0.5%) |
Table 4 shows the challenges faced and accommodation strategies used by nurses in this study. The values in the first column are the types of challenges and the percentage of nurses who faced them. The values in columns S1 to S10 are the percentages of the nurses who used the stated strategies. For example, more than half of the nurses (51.4% of the nurses) faced challenge 1 (C1): Conveying messages in English. Of the nurses who faced this challenge, most of the nurses (49%) used Strategy 1 (S1), Using a lot of hand gestures and non-verbal gestures, and used Strategy 6 (S6), Mixing English with other languages.
Table 4: Challenges Faced and Accommodation Strategies Used by Nurses When Communicating in English
Challenge | Strategies Used (Percentage) | |||||||||
S1 | S2 | S3 | S4 | S5 | S6 | S7 | S8 | S9 | S10 | |
C1 (51.4%) | 49.0 | 9.4 | 2.1 | 12.3 | 24.7 | 45.3 | 22.7 | 19.8 | 13.0 | 8.4 |
C2 (60.8%) | 54.8 | 28.1 | 10.0 | 16.6 | 25.0 | 54.9 | 7.0 | 10.4 | 16.1 | 15.4 |
C3 (58.8%) | 27.5 | 13.4 | 21.6 | 8.2 | 27.0 | 42.0 | 11.3 | 14.4 | 9.2 | 9.8 |
C4 (45.2%) | 33.4 | 18.4 | 12.7 | 12.7 | 33.9 | 39.8 | 7.4 | 14.1 | 12.7 | 16.3 |
C5 (39.2%) | 28.2 | 19.3 | 6.9 | 13.8 | 37.2 | 39.0 | 6.6 | 12.3 | 13.5 | 11.1 |
C6 (37.3%) | 30.7 | 10.1 | 11.9 | 16.7 | 37.2 | 45.9 | 13.5 | 18.9 | 17.2 | 12.1 |
C7 (40.1%) | 21.2 | 6.9 | 10.5 | 19.3 | 19.2 | 46.8 | 8.3 | 13.9 | 18.3 | 9.4 |
C8 (52.9%) | 31.2 | 13.1 | 9.9 | 14.0 | 24.4 | 36.3 | 10.0 | 14.5 | 14.1 | 16.7 |
C9 (45.2%) | 45.1 | 13.9 | 7.4 | 12.3 | 23.0 | 47.5 | 9.8 | 18.0 | 18.0 | 18.9 |
C10 (55.6%) | 18.7 | 8.1 | 6.5 | 9.8 | 20.3 | 46.3 | 13.0 | 13.0 | 23.6 | 13.8 |
C11 (45.7%) | 43.4 | 9.4 | 10.4 | 12.3 | 27.4 | 45.3 | 17.0 | 17.0 | 27.4 | 13.2 |
C12 (45.0%) | 46.3 | 11.7 | 4.3 | 16.0 | 22.2 | 53.1 | 8.0 | 13.6 | 12.3 | 16.0 |
C13 (46.1%) | 46.1 | 9.4 | 7.0 | 9.4 | 25.0 | 48.4 | 7.0 | 14.1 | 17.2 | 19.5 |
C14 (45.7%) | 48.0 | 6.3 | 5.5 | 15.0 | 28.3 | 48.8 | 11.8 | 14.2 | 15.7 | 22.8 |
C15 (55.3%) | 45.6 | 11.9 | 3.8 | 18.8 | 28.1 | 50.0 | 8.1 | 12.5 | 11.9 | 15.6 |
C16 (40.1%) | 41.2 | 12.1 | 4.8 | 15.8 | 29.1 | 48.5 | 8.5 | 13.3 | 14.5 | 16.4 |
C17 (51.6%) | 46.9 | 5.5 | 8.6 | 18.8 | 27.3 | 42.2 | 9.4 | 11.7 | 18.0 | 20.3 |
Over half of the nurses faced main six challenges: C1, C2, C3, C8, C15, and C17.
When the nurses faced C1: Conveying English messages, they would use strategies: S1: Using a lot of hand gestures and non-verbal gestures (49%) and S6: Mixing English with other languages (45.3%).
When the nurses faced C2: Understanding the patient's fast-spoken English, they would use strategies, S6: Mixing English with other languages (54.9%) and S1: Frequent use of hand movements and other non-verbal cues (54.8%).
When the nurses faced C3: Voicing out in English, they would use strategy S6: Mixing English with other languages (42%).
When the nurses faced C8: Understanding English accent/slang words, they would use strategies, S6: Mixing English with other languages (36.3%), and S1: Frequent use of hand gestures and non-verbal gestures (31.2%).
When the nurses faced C15: Using Malaysian English particles (LAH, MAH) in English conversation, they used strategies S6: Mixing English with other languages (50%) and S1: Using a lot of hand gestures and non-verbal gestures (45.6%).
When the nurses faced C17: Understanding English accent/slang words, they would use strategies, S1: Using a lot of hand gestures and non-verbal gestures (46.9%) and S6: Mixing English and other languages (42.2%) and
Overall, the predominant strategies included the frequent use of hand gestures, non-verbal cues, and code-mixing between English and other languages.
One main challenge Malaysian nurses face when communicating in English is conveying English messages. Most of the nurses in this study reported that Malay is their mother tongue, which they used to speak to their family members and friends. The nurses admitted they frequently use Malay to speak in the hospital. The nurses prefer to use Malay in daily home and community interactions. This might explain why many struggle to convey English messages, voice out in English, and understand English-speaking patients. The findings of this study correlate with Tideman and Tengelin (2019). The study showed that nurses had difficulties understanding the pronunciation, accent, and slang, of patient, as they were not used to different English pronunciations. Dragojevic, Gasiorek and Giles (2016) pointed out that unfamiliar pronunciations and accents often lead to miscommunication between nurses and patients.
This study also identified that the nurses took time to think of a reply before replying to the patients and felt nervous about speaking in English. They often have to think in their mother tongue and then translate their thoughts into English, disrupting the nurse-patient interaction. This delay is a direct consequence of the nurses' low English proficiency. The findings are similar to those of Zhao (2023), who mentioned that second languages often have problems expressing themselves in the target language, in this case, English.
The nurses used a lot of hand gestures and nonverbal gestures, as well as mixing English and other languages when they faced any English language challenges. These actions indicated that the nurses adjusted their communication style to avoid miscommunication. The nurses used convergence strategies to help interact with their English-speaking patients, corroborating with Karuthan et al. (2020). The use of convergence strategies to improve problematic interactions highlights the nurses' motivation to better understand their patients from diverse cultural backgrounds (Zhao, 2023). Convergence strategies prove that people will find a way to understand each other (Giles, 2016).
Another challenge identified by the nurses is the use of Malaysian English particles such as "lah" in conversation. While some foreign patients find this intriguing and a reflection of local culture, others perceive it as divergent from standard English, as the overuse of "lah" is considered a Misguided Accommodation (Giles, 2016). Overcoming the challenges nurses face in communicating in English is not a quick process. Employing appropriate strategies, particularly those that promote convergence, can help nurses build a closer rapport with patients (Farzadnia & Giles, 2015; Barlow et al., 2023). However, it is essential to recognise that not a single strategy will be effective for all patients. Nurses must try to understand preferences of each patient and communication styles individually. CAT is a theory that emphasises the need for a balance of communication accommodation of interlocutors to achieve better understanding (Barlow et al., 2023).
The study's findings align with previous research on language challenges in healthcare settings. This study corroborates Tideman and Tengelin's (2019) findings that Malaysian nurses experience anxiety when communicating in English, perhaps leading to a decline in competence. Meuter et al. (2015) found that in multilingual healthcare environments, patient dissatisfaction is affected by difficulties understanding rapid English speech and foreign accents. This study contributes to existing research on language obstacles by examining the accommodations employed by nurses, including code-mixing and nonverbal communication.
While code-switching and non-verbal cues are widely used as accommodation strategies, their effectiveness depends on contextual factors such as patient expectations and cultural backgrounds. According to Giles (2016), successful accommodation fosters understanding and minimises social distance. However, this study found that using the slang “lah” sometimes resulted in unintended divergence, as some patients perceived it as non-standard or unprofessional. Tideman and Tengelin's (2019) finding that nurses with low English proficiency are often perceived as less competent lends further credence to the study's conclusion that nurses experience anxiety when communicating in English. Based on variables like patient expectations, cultural differences, and the nurse's language skills, accommodation measures are not always successful. Future research should investigate the effects of these tactics on patient perceptions and healthcare outcomes.
Improving nurse-patient communication requires assessing how well accommodation techniques work. Although non-verbal cues and code-switching are frequently used, their effectiveness varies based on the patient's expectations and linguistic background. Adequate accommodations should improve mutual understanding and close communication barriers, claims Giles (2016). However, this study discovered that specific strategies, including using the Malaysian slang "lah," may reinforce linguistic diversity and have the opposite impact. Even though most nurses use convergence strategies, it is yet unknown how much this strategy reduces patient anxiety or improves satisfaction. Considering these variances, future studies should examine the impact of patient expectations on the perceived efficacy of accommodation approaches.
While this study identifies key communication barriers nurses face, it does not establish direct causal links between these challenges and patient outcomes. The findings offer a descriptive overview but do not examine the underlying causes of these difficulties or the long-term impact of accommodation strategies on patient care. Language challenges have been linked to misunderstandings and decreased patient satisfaction (Meuter et al., 2015; Hewett, Watson & Gallois, 2015). Future research should examine the impact of workplace training, nurses' language skills, and patient expectations on the efficacy of accommodation strategies. Furthermore, intervention-based studies evaluating the effects of intensive language training courses may provide more workable answers for enhancing nurse-patient interaction.
This study primarily examines language accommodation approaches, although its implications extend beyond linguistic challenges to encompass other healthcare concerns, including patient safety and care quality. Meuter et al. (2015) highlighted that inadequate adherence to directives, medical errors, and treatment delays may stem from ineffective communication between nurses and patients. Moreover, patients often perceive nurses who lack proficiency in English as less competent, potentially undermining their confidence in medical care, as Tideman and Tengelin (2019) and Zhao (2023) noted. The study's findings indicate that structured language training programs are essential for enhancing communication efficiency and minimising miscommunications that may endanger patient safety. Future research should investigate the impact of enhanced nurse-patient communication on measurable healthcare outcomes, such as reducing medical errors and increasing patient satisfaction.
Therefore, it is seen that, even though nurses actively employ various accommodation strategies to bridge language barriers, targeted training programs focusing on linguistic competence and intercultural communication are necessary to ensure effective patient interactions and improved healthcare outcomes. Nurses in Malaysian hospitals participate in annual in-house training; nevertheless, most of this training focuses on nursing responsibilities rather than English language communication. Nurses are urged to participate in communication training within their time (Tideman & Tengelin, 2019). Future research could expand on these findings by conducting qualitative studies across different hospital settings to further explore the nuances of nurse-patient communication. Thus the healthcare systems in leading medical tourism destinations like Malaysia should align their strategies with international patient expectations to improve satisfaction (Sharma, Alam, & Priya, 2025).
Despite ethical clearance from the Malaysian Ministry of Health, only one of ten medical tourism hospitals in the Klang Valley participated. Additionally, only 432 out of the expected 700 questionnaires were collected, restricting the study's applicability. The researcher achieved a response rate of 61.7%, which adheres to acceptable and adequate criteria for descriptive questionnaire research. Although elevated response rates can improve the relevance of findings, the response nevertheless provides valuable insights into the studied community. Future studies in Malaysia should involve more hospitals and an increased response rate. This would allow for more efficient comparisons and validation of the results.
Future research should incorporate inferential statistical tests which would provide deeper insights into how factors like nursing experience, education level, or patient demographics influence the effectiveness of accommodation strategies. For instance, deeper insights could be obtained by examining the potential influence of educational background or years of nursing experience on the adoption of accommodation techniques.
This study examined the English language challenges and communication accommodation strategies employed by Malaysian ESL/EFL nurses when interacting with foreign English- speaking patients in a medical tourism-oriented hospital. The findings reveal that, despite their years of English exposure in educational settings, nurses face significant challenges, particularly in conveying messages, voicing out in English, and understanding patients' accents or pronunciations. These difficulties often lead to using code-mixing and non-verbal gestures to facilitate communication, reflecting the nurses' efforts to accommodate their patients linguistically.
Communication Accommodation Theory (CAT) provided valuable insights into how these nurses adjust their speech to foster better understanding. While nurses predominantly employ convergence strategies such as simplifying language or hand gestures, the occasional divergence, seen in local English particles like "lah," highlights a unique cultural dynamic that patients could misunderstand. Addressing these linguistic gaps is critical to improving patient care, and a greater emphasis on spoken English in nursing training programs is recommended. Moreover, mentorship programs led by senior nurses should focus on improving English proficiency to ensure effective communication and patient satisfaction.
The authors declare that they have no competing interests.
The researchers sincerely extends heartfelt gratitude to the Ministry of Health, the hospital administration, and all the nurses who generously contributed their time and effort to participate in this study. Their support and cooperation were invaluable in ensuring the successful completion of this research. Furthermore, the researcher acknowledges that this study was conducted without any external funding or grants.
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