Language barriers and professional identity: A qualitative interview study of newly employed international medical doctors and Norwegian colleagues
Introduction
A significant number of doctors leave their homeland to work in other countries [1], [2]. In Norway, approximately 16% of practicing medical doctors hold foreign citizenship, with international medical graduates (IMGs) comprising a significant proportion of the GP workforce [3] and representing approximately 25% of senior doctors in hospitals [4]. IMGs have become an important resource for Norwegian health services, similar to other European countries [2], USA, Canada and Australia [1]. Doctors from EU/EEA countries are not subject to national language requirements due to the principle of free movement of labor. Most IMGs in Norway are from Germany and neighboring Scandinavian countries [5]; however, 3.5% of practicing doctors are from countries outside the EU and must take a high-level Norwegian language examination for authorization. Ultimately, the employer is responsible for ensuring that their healthcare personnel has adequate language skills. Still, IMGs often have some degree of language difficulty, whether they come from countries neighbouring Norway or from ones that are geographically and/or culturally distant [6], [7], [8], [9].
International research has shown that IMGs often experience language barriers [7], [10], [11], [12], [13], [14] and find that their new patients and colleagues have different expectations regarding professional communication compared to what they have learned and practiced in their homeland [6], [7], [8], [9], [11]. Schwei et al. [15] reviewed the literature regarding language barriers in health care concluding that the topic is well explored and that “researchers worldwide should move away from simply documenting the existence of language barriers”. However, they also state, “language barriers adversely affect ‘quality of care; and patient and provider satisfaction’ among other things, calling for more research to understand and rectify such barriers in health services. Indeed, Lineberry’s review of educational interventions for IMGs [14] states that the literature on how IMGs learn language skills is insufficient, pointing to a need for interventions to accommodate language barriers.
To understand the implications of practicing health care in a new language, it is important to be aware of the challenges healthcare professionals encounter when immigrating. In general, immigrants report that both the knowledge and the status they had achieved in their home countries have less value in their new countries [16], [17]. These and other experiences of loss are common, as are a lack of knowledge about their new host country and its health care services [18]. Far from being immune to these challenges, IMGs who begin their careers in a country other than the one in which they were educated find that it can be demanding, and, for some, it can cause emotional stress and loss of self-esteem [10], [19], [20], [21], [22], [23], [24]. Language barriers and other acculturation stress factors could threaten the IMGs’ professional identity. The concept of professional identity (i.e., a person’s experience of understanding and mastering his or her profession, possessing adequate knowledge, and applying that knowledge to their work) has become central to medical education [25], [26]. A key element of professional identity is the individual’s perception of their own professionalism [26] or “sense of being professional” [25], [27]. This perception is neither inherent to the individual nor static; it is an ongoing process [26] related to one’s experience of being able to interact effectively with one’s environment [28]. In addition, acculturation stress affects the IMGs’ ability to adapt to their new surroundings [20], probably including learning a new language and dealing with language barriers.
This study explores the issue of language barriers using semi-structured interviews with newly-employed IMGs and native Norwegian health providers. This study was explorative, aimed at enlightening experiences and views on everyday professional collaboration. A persistent theme was the wide spectra of experiences of language barriers, in particular how these language barriers could influence the IMGs’ sense of self and ability to provide quality healthcare.
Section snippets
Methods
To gain insight into experiences of working relationships between native Norwegian health providers and new IMGs (who would be unfamiliar with the Norwegian health care system and practicing in the Norwegian language), we planned qualitative interviews. Our intention was to work inductively to explore and present health providers’ experiences and views about a topic we know concerns health providers, patients, and government administration. We conducted semi-structured interviews that focused
Overview
All participants, both IMGs and Norwegian health personnel, spontaneously described language barriers as the most prevalent problem in their everyday collaborations. Indeed, many of the participants brought up the topic at the beginning of the interview, some even before it had formally begun. Further description and specifications of these difficulties revealed a wide spectrum of situations where they had experienced such barriers. An important phenomenon in both IMGs and native Norwegian
Discussion
Literature shows that both IMGs [6], [7], [10], [11], [12], [19], [35] and colleagues of IMGs [12] experience language barriers. The results from this study reveal that IMG and Norwegian health care providers have concerns regarding a number of topics that could be considered language barriers; therefore, remediation relies on a multifaceted approach. In addition, language shortcomings by both participant groups were associated with feelings of insecurity during interactions and potential loss
Acknowledgements
The Norwegian Research Council funded this work (grant number: 204548, 2010).
We acknowledge Sissel Steihaug (MD, PhD) for patient method guidance in all parts of this study and critical comments that improved this paper.
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