This study is inspired by the researcher’s previous work on Kuwaiti firefighters, which examined the role of English in the rescue and security sector (Almubayei, 2022). Similarly, paramedics, like firefighters, are routinely required to interact with individuals from diverse linguistic and cultural backgrounds, often under urgent and high-pressure conditions. In such critical encounters, there is limited time to navigate language barriers or address cultural differences; therefore, biases must be suspended, and communication must be both efficient and empathetic (Almubayei, 2022; Al Shamsi et al., 2020; Muller et al., 2020). Consequently, professionals operating within emergency and rescue services must possess strong linguistic competencies and sociocultural awareness to perform their duties effectively.
Accordingly, this study seeks to address two central research questions: first, what are the linguistic and sociocultural challenges EMTs face in their interactions with patients during emergency situations? Second, are EMTs adequately prepared through their academic training and English language instruction to manage potential linguistic and sociocultural miscommunications?
The Central Statistical Bureau, established in the early 1960s following Kuwait’s independence, functions as the official governmental institution responsible for statistical data collection and reporting. According to the Central Statistical Bureau of Kuwait, the national population is estimated at 4,913,271, comprising 1,545,781 Kuwaiti nationals and 3,367,490 non-Kuwaitis as of January 2024 (Central Statistical Bureau, n.d.). Therefore, a significant portion of the population consists of non-Arabic speakers, making English, as a global lingua franca, a common communicative medium among individuals from various linguistic backgrounds (Almubayei, 2022)
Furthermore, as of 2022, the Central Statistical Bureau reported that a total of 13,135 paramedical staff were employed under the Ministry of Health, including 6,797 Kuwaitis and 6,338 non-Kuwaitis (Central Statistical Bureau of Kuwait, n.d.). In response to the growing demand for emergency medical services (EMS), Dr. Abdulla Alfaras, Assistant Undersecretary for Medical Support Services Affairs, affirmed the Ministry's ongoing commitment to enhancing the competencies of EMTs and paramedics. He also announced the deployment of 100 new ambulances in 2024 (Kuwait News Agency, 2024). Dr. Alfaras, an internal medicine specialist, currently serves as the Head of Internal Medicine at AlAdan Hospital and has formerly held the same position at AlSabah Hospital since 2022 (Alanba, 2023).
Moreover, Kuwait News Agency, KUNA (2024) reported that ten new emergency stations were completed in 2024, bringing the total number of EMS stations to 86. EMS operations have now expanded to include 200 ambulances, which collectively responded to 126,000 emergency calls and transported 128,000 patients, maintaining an average response time of approximately ten minutes. However, despite these developments, the sector continues to confront an ongoing shortage of qualified and advanced EMTs, particularly amid growing global competition and rapid technological advancements (Kuwait News Agency, 2024).
Although research on the relationship between patients with limited English proficiency (LEP) and emergency medical providers, including firefighters, EMTs, and paramedics, remains limited (Stadeli et al., 2023), some existing studies (Espinoza & Derrington, 2021; Meischke et al., 2010; Sadaka, 2022; Stadeli et al., 2023) have examined the broader struggles of LEP individuals in accessing healthcare and emergency services. These challenges include communication difficulties with healthcare providers such as doctors, nurses, and EMS personnel, especially in high-stakes situations such as accidents, fire hazards, and medical emergencies (Almubayei, 2022; Al Shamsi et al., 2020; Muller et al., 2020)
However, the present study offers a particularly novel perspective by focusing on EMS professionals who themselves have LEP and who experience communication challenges with non-Arabic-speaking patients, many of whom may also possess limited English proficiency during prehospital care encounters. This issue is especially significant given the vital role that EMTs and paramedics play in diagnosing patients, ensuring patient safety, and performing critical interventions under hazardous and time-sensitive conditions. In order to execute these responsibilities effectively, EMTs must demonstrate not only clinical competence but also linguistic flexibility and sociocultural sensitivity (Muller et al., 2020).
Prior research has primarily focused on patients with limited English proficiency (LEP) in English-speaking contexts (Espinoza & Derrington, 2021; Meischke et al., 2010; Sadaka, 2022; Stadeli et al., 2023) or on non-Arabic-speaking EMTs treating Arabic-speaking patients (Nuguid, E. L., & Muir, F., 2019). On the other hand, his study offers a novel perspective by examining the reverse scenario: Arabic-speaking EMTs responding to non-Arabic-speaking patients within Kuwait's multicultural and multilingual healthcare environment. Given Kuwait’s demographic composition, where expatriates constitute the majority of the population, this study addresses a critical yet underexplored area of EMS practice. By employing a mixed-methods approach that integrates both quantitative and qualitative data, the study provides a comprehensive understanding of how linguistic barriers, sociocultural sensitivities, and public perceptions collectively shape EMT-patient interactions. This research not only fills a significant gap in the existing literature on EMS communication in the Gulf region but also offers practical recommendations for improving training, policy, and public awareness to enhance patient safety and care quality in emergency medical services.
Therefore, this study aims to investigate the academic qualifications, linguistic competence, and sociocultural adaptability of Kuwaiti paramedical personnel. Furthermore, it seeks to assess their preparedness in serving non-Arabic-speaking populations and to offer evidence-based recommendations for enhancing communication between EMS providers and the increasingly diverse patient communities they serve.
This section reviews the existing literature concerning the relationship between patients with limited English proficiency (LEP) and Emergency Medical Technicians (EMTs) and paramedics, in order to illustrate the communication challenges that may arise due to both linguistic and sociocultural differences. Given that emergencies often present life-or-death situations, communication becomes the most critical skill to ensure rapid and accurate understanding of the patient’s condition, which is necessary for effective intervention.
However, when healthcare providers lack the basic communication skills necessary to share a common language or to navigate diverse social and cultural practices, patients are at greater risk of being misunderstood, misdiagnosed, or improperly treated (Al Shamsi et al., 2020; Muller et al., 2020; Noack et al, 2020; Nuguid and Muir, 2019). Hence, this study is grounded in the essential role that emergency service providers play in ensuring patient safety during rescue situations, while specifically focusing on the communication skills and English language proficiency of EMTs themselves. This focus contrasts with much of the previous literature, which has primarily examined patients with LEP rather than the paramedics or EMTs who serve them.
Paramedics require not only technical expertise but also a comprehensive set of non-technical competencies, including effective communication, emotional intelligence, situational awareness, flexibility, safety, and the ability to adapt to various conversational styles in high-stress situations, which is considered indispensable (Australian Paramedical College, n.d.).
Furthermore, language barriers significantly obstruct LEP individuals from accessing healthcare services, educational materials, and emergency assistance. When attempting to contact emergency services (e.g., 911), LEP patients may experience critical delays in the recognition of life-threatening conditions such as cardiac arrest and may encounter complications in receiving telephone-assisted CPR instructions, (Centers for Disease Control and Prevention, 2015; Moissac & Bowen, 2018; Perera et al., 2021). Consequently, these barriers can have direct and potentially fatal consequences.
Moreover, patients with LEP are more likely to incur higher healthcare costs, experience repeat hospital visits, receive inadequate management of chronic diseases, and face elevated risks of morbidity and mortality (Sadaka, 2022). Miscommunication between healthcare providers and patients undermines the quality of care, reduces satisfaction on both sides, and presents significant threats to patient safety (Al Shamsi et al., 2020; Muller et al., 2020; Noack et al, 2020). Conversely, when professional language services are made available, communication improves, patient satisfaction rises, and overall safety outcomes are enhanced (Flores, 2006).
In addition, research from Japan has shown that 33% of 55 paramedic training institutions failed to include English for Medical Purposes (EMP) within their curricula, instead offering only general English courses. The study strongly recommended integrating EMP instruction into training programs for both EMTs and paramedics to enhance real-world communication skills (Hidetsugu, 2012). Similarly, in the United States, the enactment of language access laws has led to the development of linguistically trained healthcare providers in each state; for example, California alone employs approximately 250 trained professionals who serve non-English-speaking populations (Deering, 2023). Furthermore, Quan and Lynch (2010) argue that investing in professional language services is more cost-effective in the long term than managing the consequences of communication failures.
The Institute of Medicine’s report
However, language barriers alone do not fully account for the challenges faced by LEP patients. Cultural differences and implicit biases also create substantial obstacles (Stadeli, 2019; Stadeli et al., 2023). Indeed, bilingualism alone does not guarantee effective care, as cultural competence is equally critical in building trust and delivering appropriate treatment. Relying exclusively on interpreters or translation tools may actually heighten patient anxiety and obstruct rapport-building between patients and providers (Whiteside, 2022). Furthermore, emergency telecommunicators have identified calls involving LEP individuals as especially stressful and challenging to manage (Meischke et al., 2010). Therefore, the implementation of language training programs and workforce diversity initiatives becomes essential to mitigate bias, strengthen patient-provider trust, and minimize delays in care (Heath, 2023).
Moreover, empathy and cultural sensitivity, combined with paramedic-specific English proficiency,are vital for improving patient outcomes in EMS. Core communication competencies such as active listening, questioning, decision-making, problem-solving, and interpersonal communication are foundational skills for effective practice in emergency medicine (Lokesh, 2020). In the absence of these skills, LEP patients risk being perceived as "othered," which may lead to inaccurate assumptions regarding their intelligence, cultural values, or religious beliefs (Espinoza & Derrington, 2021). In addition, language and cultural barriers may also negatively influence healthcare-seeking decisions among patients with mental health disorders, further exacerbating healthcare disparities (Slade & Sergent, 2023).
Several scholars have called for more research specifically examining language barriers within EMS contexts. Recommended strategies include increasing public awareness regarding how to appropriately engage with emergency services, enhancing linguistic and cultural sensitivity among EMS staff, and promoting greater diversity within emergency care teams (Muller et al., 2020). Stadeli (2019) further emphasizes the need for targeted education on cultural norms and practices, both for EMS personnel and for the general public, to increase understanding of the roles and responsibilities of EMTs, paramedics, and firefighters. She additionally suggests that EMS personnel be trained to learn basic phrases in commonly spoken foreign languages to foster rapport and reduce mistrust with LEP communities.
In the Gulf region, similar challenges are evident; however, research in this context remains limited. For instance, a study conducted in Saudi Arabia highlighted communication gaps between Arabic-speaking patients and expatriate nurses, recommending interventions such as Arabic language instruction or phrasebook tools to improve patient outcomes (Al-Harasis, 2013). Nuguid and Muir (2019) conducted a qualitative study focusing on interactions between non-Arabic-speaking paramedics and Arabic-speaking patients in Kuwait, identifying recurring incidents of miscommunication, mistrust, and misdiagnosis. They recommended providing Arabic language training for foreign EMS staff to ensure better patient safety.
In contrast to these earlier studies, the present research adopts a novel approach by examining communication challenges from the opposite perspective, Arabic-speaking EMTs and paramedics who interact with non-Arabic-speaking patients. By employing both quantitative (surveys) and qualitative (semi-structured interviews) research methods, this study aims to evaluate the preparedness of local EMS personnel in serving Kuwait’s multilingual patient population and to propose practical strategies for bridging communication gaps in emergency medical care.
This study seeks to collect data from local Kuwaiti paramedics and Emergency Medical Technicians (EMTs) regarding their academic qualifications, English language proficiency, and the linguistic and sociocultural barriers they encounter during patient interactions in emergency situations, which may compromise communication and patient safety.
To achieve this, data were collected using both a survey and fieldwork interviews. The survey, originally designed by the author, was disseminated anonymously via multiple social media platforms, including Instagram, Twitter, and MyU, a Kuwaiti educational platform used by educators and students across schools and colleges (see Appendix A). Notably, this survey was adapted from a previous instrument developed by the author in an earlier study investigating language use in the emergency and rescue sector (Almubayei, 2022).
The survey consisted of multiple-choice questions, and the resulting data were analyzed quantitatively. A total of 187 Kuwaiti EMTs (both men and women) completed the survey. Among the respondents, 69% were male and 31% female. The majority (58.3%) were between 21 and 30 years of age. Furthermore, 91.4% of the participants held a diploma, while only 7% reported holding a bachelor’s degree.
In addition to the survey, semi-structured interviews were conducted with a subset of EMS personnel, including both male and female EMTs, as well as the Head of EMS. These interviews were incorporated to complement the quantitative survey data with qualitative insights, thus enriching the overall analysis. The fieldwork visits to various emergency centers provided a holistic and comprehensive understanding of EMTs’ experiences, closely resembling ethnographic field studies.
All interview questions were developed by the author. Importantly, participation in the interviews was entirely voluntary, with participants agreeing to remain anonymous regarding both their personal identities and the specific emergency centers at which they worked. The participants were not pre-selected; rather, they volunteered spontaneously during the fieldwork visits and expressed a strong interest in contributing to the study and reviewing its findings.
The data for this study were collected through two complementary instruments, both developed by the author: a structured electronic survey and a series of fieldwork interviews. These instruments were specifically designed to address the research objectives, which focus on identifying the linguistic and sociocultural challenges faced by EMTs during their interactions with patients in emergency situations, and evaluating whether EMTs are adequately prepared through their academic training and English language instruction to manage such challenges effectively.
The electronic survey consisted of 22 multiple-choice questions, administered in the Arabic language. It began by collecting basic demographic information from participants, including their age, gender, education level, and residential governorate. The remainder of the survey explored a range of variables central to the research, such as EMTs’ self-reported English language proficiency, their confidence in English conversational skills, the frequency with which they encounter non-Arabic-speaking patients during emergency situations, the perceived usefulness of prior English language courses, and their experiences with both linguistic and sociocultural barriers in the field. Additional sections assessed participants’ perceptions of patient safety risks associated with language and cultural barriers, as well as their attitudes towards the importance of cultural sensitivity within emergency medical practice.
Once the data were collected, the responses were quantitatively analyzed using descriptive statistics generated through Google Forms. From the full set of survey questions, the author identified several key items to present in detail, as they directly reflect the study’s core themes. These included questions regarding whether English courses should emphasize conversation and communication; whether English instruction should focus on field-specific medical terminology and jargon; whether paramedics should demonstrate increased cultural and linguistic sensitivity; and whether non-Arabic speakers living in Kuwait should be encouraged to learn Arabic and adapt to the local culture to minimize communication barriers.
In total, 187 Kuwaiti EMTs participated in the survey. Their responses varied across the provided Likert-scale options, ranging from "strongly agree" to "strongly disagree," with an additional neutral option of "indifferent." The findings reveal that 86.1% of respondents reported being able to speak English. Among this group, 15.5% rated their English proficiency as excellent, 47.1% as very good, and 33.7% as good. Regarding their English conversational ability, 43.3% rated their skills as very good, 36.9% as good, and 12.8% as excellent.
The data further indicate that a significant majority of respondents, approximately 97.3%, frequently encounter non-Arabic-speaking patients during emergency calls, which underscores the multilingual and multicultural complexity of prehospital care in Kuwait. When asked about their prior English language education during their paramedic training, 57.8% of participants reported having completed more than two English courses, while 26.2% had taken two courses, and 14.4% had taken only one. Regarding the perceived usefulness of these courses, 29.4% rated them as excellent, 31.6% as very good, and 24.1% as good.
Further examination of the curriculum content revealed that 36.4% of participants identified vocabulary as the primary focus of their English courses, while 26.7% emphasized conversation, 20.9% reported reading and writing, and 16% indicated grammar. These results suggest a clear need for a pedagogical shift in EMS language training, emphasizing practical and real-time communication skills that are directly applicable to emergency scenarios. In addition to conversational fluency, greater attention should be given to developing medical terminology, reading comprehension, and rapid documentation abilities, given that EMTs routinely relay critical prehospital information to receiving hospital staff.
The results show a strong consensus among participants regarding the importance of improved language instruction. An overwhelming majority of 96.7% agreed that English courses should prioritize communication skills, with 66.8% strongly agreeing and 29.9% agreeing. Similarly, 92.5% of respondents supported the inclusion of field-specific medical terminology and jargon in their English instruction. These quantitative results provide an important foundation that will be further contextualized and enriched through the qualitative data derived from the subsequent fieldwork visits and interviews.
|
|
|
|
|---|---|---|
| The English courses should focus on conversation and communication. | 66.8% | 29.9% |
| The English courses should focus on the field’s terminology and jargon. | 66.8% | 25.7% |
| Paramedics should be more sensitive culturally and linguistically to people from different languages and cultures. | 47.1% | 43.9% |
| Non-Arabic speakers in Kuwait have to learn Arabic and the local culture to overcome linguistic and cultural differences. | 48.7% | 40.6% |
Source: By the author
Furthermore, a substantial majority of 87.1% of respondents agreed that the EMS study program should include additional English language courses. Beyond questions related to their formal education, the survey also explored the practical challenges that EMTs encounter as a result of linguistic and cultural barriers in the field. Specifically, 85.6% of participants reported experiencing communication difficulties with non-Arabic-speaking patients during the course of their duties, whereas only 14.4% indicated that they had never faced such challenges.
In relation to cultural barriers, 64.2% of respondents acknowledged having difficulties communicating with individuals from different cultural backgrounds. Meanwhile, 18.2% reported that they rarely encountered such issues, and 17.6% stated that they had not experienced them at all. With regard to patient safety concerns, 62% of participants agreed that non-Arabic-speaking patients are at increased risk during emergency situations due to language barriers, while 33.1% disagreed with this assessment. Similarly, 56.7% believed that cultural differences could also elevate patient safety risks, whereas 38% expressed disagreement.
When participants were asked to identify the most effective strategies for overcoming language and communication barriers in the field, 46.5% expressed a preference for post-graduation training courses. In comparison, 22.5% favored the introduction of additional English language classes, an identical proportion supported the use of translation applications and devices, and only 8.6% advocated for the employment of professional translators. These findings suggest that most EMTs prioritize practical skill development and applied training over more conventional classroom-based instruction.
Notably, 91% of respondents agreed that EMTs should demonstrate greater cultural and linguistic sensitivity when working with patients from diverse backgrounds, with 47.1% strongly agreeing and 43.9% agreeing (Table 1). In addition, 84.5% of participants endorsed the integration of psychology and cross-cultural communication courses into EMS training curricula. An alternative proposal presented to participants suggested that non-Arabic-speaking residents living in Kuwait should also be encouraged to learn Arabic and familiarize themselves with local cultural norms as a means of narrowing communication gaps. This recommendation received strong support from 89.3% of respondents (Table 1).
After analyzing the statistical data of the survey, it is time to discuss the fieldwork visits to EMS centers and analyze the interviews qualitatively for a more holistic understanding of the nature of this significant field.
In order to complement and enrich the quantitative findings obtained from the survey, two sets of semi-structured interview protocols were developed, one tailored for EMTs and another specifically designed for the Head of EMS. These interviews were intended to offer deeper insights into the significant role that effective communication plays in the daily responsibilities of EMTs, while also exploring their communication challenges, workplace experiences, and perceptions regarding the adequacy of their training. The qualitative data collected through these interviews were subjected to thematic analysis and subsequently interpreted in the context of the study’s research questions.
The participants who took part in the interviews were not involved in the survey portion of the study. Instead, they engaged directly with the author during the field visits in an informal and conversational manner. The interviewees were notably welcoming and cooperative, readily sharing their experiences and professional encounters in the field. The sole condition expressed by participants was the assurance of anonymity for both their personal identities and the specific emergency centers at which they were employed. This anonymity allowed them to speak candidly and honestly about the realities of their work. The interviews focused on personal narratives and experiences, particularly instances involving communication barriers encountered during emergency interventions. These narratives form the foundation of the qualitative findings discussed in this section.
The fieldwork consisted of visits to ten different emergency centers, where discussions were held with groups of EMTs, all of whom were male. In addition to these site visits, seven telephone interviews were conducted with female EMTs. While the interviews followed a semi-structured format, participants were encouraged to speak freely and elaborate on issues they found most relevant. Nonetheless, several core themes consistently guided the interviews, including the essential skills required by EMTs, the structure and content of their academic training, their English language proficiency, the nature of their training courses, the specific language challenges they face, and their adaptive strategies for managing communication in multicultural emergency situations.
Several contextual and cultural factors shaped the nature of these fieldwork visits and presented unexpected challenges for the data collection process. The interviews were conducted during the holy month of Ramadan, a period that altered the operational routines of EMS centers, including shortened morning shifts and reduced staff availability. Many Kuwaiti EMTs were on leave during this period, which further limited access to the intended target population. As a result, the majority of EMTs encountered during the field visits were non-Kuwaiti nationals or stateless individuals, commonly referred to locally as Bidoon, who were born and raised in Kuwait. In addition, the EMT workforce included individuals from a diverse range of nationalities, such as Egyptian, Syrian, Jordanian, Somalian, Palestinian, Indian, Indonesian, Filipino, Saudi, Iraqi, and Iranian backgrounds. This diversity introduced a methodological complication, as the study initially aimed to focus exclusively on Kuwaiti EMTs.
Other logistical difficulties further complicated data collection. Heavy traffic during fasting hours and the remote locations of many EMS centers, often situated in industrial zones near oil refineries and power stations, made some visits particularly challenging. Moreover, as a female researcher operating within a male-dominated profession in a conservative Middle Eastern context, securing access and conducting formal interviews required navigating additional cultural sensitivities and institutional protocols. In some centers, staff shortages limited the number of available participants, and in several instances, EMTs were called away to respond to emergency situations in the middle of interviews, further reflecting the operational pressures and staffing limitations characteristic of the EMS sector.
Additionally, the informal and close-knit culture that often exists within EMS centers influenced the interview dynamics. Many EMTs share strong collegial relationships, which made traditional structured interviews feel somewhat intrusive. As a result, several interviews naturally evolved into informal group discussions, which, while deviating from the original methodological design, nonetheless yielded rich and valuable qualitative data. The inclusion of non-Kuwaiti Arabic-speaking EMTs, including both stateless individuals and Arab expatriates, ultimately became both necessary and ethically appropriate. Excluding these willing participants would have risked compromising the inclusivity and representativeness of the study. Importantly, these non-Kuwaiti EMTs were Arabic-speaking professionals who had either been born in Kuwait or had lived there for many years and faced similar communication challenges when treating non-Arabic-speaking patients, thereby fitting well within the scope of the study’s focus on linguistic and sociocultural barriers in emergency care.
The openness and solidarity expressed by participants were particularly notable. As one Kuwaiti participant succinctly remarked, in response to inquiries about whether there were Kuwaiti EMTs available for the study: “There is no difference. We are all brothers here.” This sentiment reflects the collaborative nature of the EMS workforce, irrespective of national identity. Consequently, adjustments to the original research design were implemented to accommodate these realities, ensuring that data collection remained both practical and culturally sensitive without compromising the integrity of the study.
Furthermore, locating active-duty Kuwaiti EMTs proved difficult, as many now occupy administrative roles, work exclusively morning shifts, or were unavailable during the data collection period. This scarcity was later confirmed by the Head of EMS, who acknowledged the relatively low number of Kuwaiti nationals currently serving in operational EMS roles.
In total, ten EMS centers across various regions of Kuwait were visited during the course of this study. In adherence to ethical standards and participant privacy, the names and exact locations of these centers are withheld, as requested by the participants. The EMS centers varied considerably in size and operational function; some served as major hubs affiliated with hospitals, while others operated as smaller facilities dedicated to local residential areas.
During the first site visit, no Kuwaiti EMTs were available for interview. Nevertheless, an Iranian EMT volunteered to share his experiences, providing valuable insight into the communication challenges present in his daily work. He recounted two specific incidents where language barriers had significantly impacted patient care. In the first case, he responded to an emergency involving a Turkish mother whose infant was suffering from seizures. Lacking any shared language, he resorted to contacting his Turkish hairdresser, who was fluent in Arabic, to assist in interpreting the mother’s description of the child’s symptoms. In another incident, he was called to assist a deaf patient and was forced to rely entirely on non-verbal communication, using gestures and body language to assess the situation and determine the patient's needs. Reflecting on these experiences, he observed that EMS work is often perceived as undesirable due to its demanding nature, high stress levels, and insufficient financial compensation,a perspective that was similarly echoed by multiple participants throughout the fieldwork.
At the second EMS center, which was located within a hospital complex, a Syrian EMT described encountering similar communication obstacles. While responding to a vehicular accident, he treated a patient of African descent who was unable to communicate in either Arabic or English. In the absence of any common language, the EMT was compelled to rely solely on body language, gesturing to various parts of the patient’s body in an effort to identify the location and severity of injuries.
At the third EMS center, a semi-structured interview was conducted with a Kuwaiti EMT stationed at a smaller residential facility. This participant, who possessed fourteen years of professional experience, offered extensive insights into both the development of EMS education in Kuwait and the evolving challenges faced in the field. He provided a comparative account of the two primary EMS training institutions in Kuwait: the former Emergency Medical Institute and the more recently established College of Medical Sciences, which has now replaced it. The previous program at the Emergency Medical Institute spanned one year, with instruction delivered in both Arabic and English; however, English instruction was largely limited to medical terminology and reading comprehension. In contrast, the current program at the College of Medical Sciences extends over two and a half years and is conducted primarily in English, offering four dedicated English courses, including one focused on medical terminology.
When asked about the most critical subjects that should be incorporated into EMT training, the participant emphasized the importance of psychology, noting its relevance in helping paramedics better understand and effectively engage with patients under distress. This viewpoint is consistent with the findings of the survey, wherein 84.5% of respondents supported the inclusion of psychology within the EMS curriculum. The participant also underscored the psychological and emotional burdens associated with EMS work, referencing a recent incident where an EMT had tragically taken his own life as a result of occupational stress. He identified several contributing stressors, including inadequate financial remuneration, outdated or poorly maintained ambulances, widespread social stigma surrounding the profession, and the public misperception that EMTs function solely as patient transporters rather than as highly trained medical professionals.
Addressing the study’s core research question on managing linguistic barriers, the participant candidly remarked, “How can I help him if I don’t know what’s wrong with him?” In situations where no shared language exists, he often resorts to non-verbal communication, relying on gestures and body language to assess patients. In many cases, bystanders who speak the patient’s language, often Indian or Bengali, given Kuwait’s large expatriate population, are enlisted to assist with translation, particularly in accident scenarios involving members of these communities.
Beyond linguistic challenges, the participant also identified significant sociocultural obstacles that can interfere with emergency care delivery. He recalled instances where cultural norms and beliefs prevented EMTs from providing timely assistance. In one case, a family member denied an EMT entry into their home, perceiving the EMT to be too effeminate and therefore unfit to treat the patient. In another incident, a son refused to allow male EMTs to accompany his mother in the ambulance’s rear cabin, citing cultural concerns about propriety. Additionally, female patients sometimes rejected treatment altogether from male EMTs, mistakenly believing that EMTs serve merely as transporters without any formal medical training.
The interviewee further expressed concerns regarding staffing shortages and insufficient medical equipment. Many ambulances, he explained, were either outdated and overused or newer but poorly designed to meet the demands of fieldwork. In terms of communication infrastructure, EMTs typically did not engage directly with call center staff and were often unaware of whether emergency calls were processed in languages other than Arabic. Nonetheless, it is generally assumed that English is used in call centers, given its widespread role as a lingua franca in Kuwait. Within ambulances, standard operational protocol ensures that at least one EMT on each shift is fluent in Arabic to facilitate basic communication needs.
Common operational challenges reported by participants included congested traffic, poor road conditions, uncooperative bystanders at emergency scenes, and frequent interference from patients’ family members, all of which further complicate EMS response efforts and compromise timely patient care.
During the fourth fieldwork visit, conducted at the main administrative headquarters of the EMS, the researcher was able to interview the Head of EMS, Dr. Ahmad AlShatti. Although this interview was conducted without prior appointment, Dr. AlShatti generously allocated an hour to the discussion and provided both qualitative insights and statistical data regarding the EMS workforce. While the primary objective of the fieldwork was to collect qualitative data, this particular interview yielded important workforce statistics that help contextualize many of the qualitative findings. According to the 2024 annual EMS evaluation obtained from the Head of EMS during the interview, Kuwait operates 87 EMS centers staffed by 2,288 personnel, supported by 281 ambulances. Among the personnel, 1,882 are male and 406 are female, with a total of 2,069 staff members specifically trained in prehospital emergency services, including EMTs, advanced EMTs, paramedics, and nursing staff. Notably, only 484 members of the EMS workforce are Kuwaiti nationals, representing just 21.2% of the total, highlighting the profession’s limited appeal among the Kuwaiti population.
In addition to providing statistical data on workforce demographics by nationality and gender, Dr. AlShatti elaborated on the essential skills required for EMTs, the recurring challenges they face, and the significance of linguistic and sociocultural competence in the EMS field. He acknowledged that many Kuwaiti EMTs have left the profession for more lucrative opportunities in sectors such as oil, the military, or have transitioned into administrative roles within the EMS itself. Although no formal questions about English language instruction were posed, Dr. AlShatti addressed the critical role of English in EMS operations. He emphasized that, as a majority of EMS patients are non-Kuwaiti, particularly among the non-Arab expatriate population, proficiency in English is indispensable for effective communication. However, many recent EMT graduates reportedly lack adequate English language skills. According to Dr. AlShatti, strong language proficiency is becoming increasingly vital as the EMS sector moves toward digitalization, international accreditation, and standardized reporting systems that require EMTs to produce swift, accurate, and often English-language documentation for hospital staff. He described language barriers as potentially catastrophic, particularly in the absence of standby or ad hoc translators. Citing a specific incident, he described how a Korean patient, unable to speak either Arabic or English, was forced to rely exclusively on gestures to communicate symptoms such as diarrhea and dysuria. Dr. AlShatti concluded the interview by underscoring that EMS professionals must excel in both clear and compassionate communication, remarking, “This is a health and safety field,misunderstandings are not an option.”
The fifth field visit, which lasted approximately one hour and twenty minutes, took place at a large EMS center serving multiple residential districts. Here, a Kuwaiti EMT with thirty-one years of professional experience provided highly detailed accounts of the linguistic and sociocultural challenges encountered in the field. He explained that communication breakdowns often stem from patient families who are either uncooperative or obstructive. When emergencies involve patients or families who speak neither Arabic nor English, the absence of qualified translators becomes a significant obstacle. In such cases, EMTs may resort to using translation tools such as Google Translate, as occurred during one incident involving a French-speaking patient who sustained a back injury after falling in a bathroom. In another case, EMTs enlisted the assistance of a Chinese nurse to interpret for a group of seventy-five Chinese nationals suffering from chronic diarrhea. It was later determined that the patients had consumed dog meat, which is illegal in Kuwait, resulting in severe food poisoning.
Beyond language difficulties, sociocultural issues further complicated emergency responses. Patients sometimes hesitated to disclose full medical histories due to the stigma surrounding mental illness, substance abuse, or fear of deportation tied to uncertain residency status. Conservative families often objected to male EMTs providing care for female patients, based on cultural norms that discourage cross-gender interaction in medical contexts. The interviewee noted that many of these challenges are rooted in the public’s limited understanding of EMS roles and the broader lack of awareness surrounding the professional responsibilities of EMTs.
He recounted multiple incidents that highlight the consequences of these misunderstandings. In one case, a husband refused to allow a male EMT to assist his wife during childbirth, thereby risking the safety of both mother and child. In another situation, a family concealed the fact that their elderly mother had already passed away from an infectious disease in order to transport her body home for religious funeral rites. Additionally, in a separate case, a Hindu patient suffering from a wrist injury adamantly refused treatment, repeatedly stating, “Don’t cut it,” in reference to his religious bracelet, which EMTs needed to remove for medical reasons.
These examples demonstrate that cultural barriers can be just as dangerous as linguistic ones. Even in cases where a shared language exists, differing cultural beliefs and practices can heavily influence decision-making during emergencies, often undermining the delivery of timely care.
The sixth EMS center, located in a residential area, was staffed exclusively by male personnel, with the center head being the sole Kuwaiti staff member present. During a one-hour-and-ten-minute interview, a Palestinian EMT with forty-three years of experience emphasized the centrality of effective verbal communication in emergency care. He asserted that "successful communication is essential in this job" and emphasized how easily errors can occur when family members interfere with diagnosis or treatment due to misconceptions about EMT roles. Consistent with other participants, he argued that hands-on field experience is more valuable than formal academic training in preparing EMTs for real-world challenges. He also observed that Indian EMTs often serve as valuable linguistic intermediaries, given their ability to speak both English and Urdu, languages widely used among Kuwait's sizable South Asian communities.
The seventh and eighth EMS centers visited were smaller facilities where no staff were available at the time of the visit, underscoring the persistent nationwide shortage of EMTs.
At the ninth EMS center, a major regional station, a 35-minute interview was conducted with two non-Kuwaiti stateless EMTs, who had three and one year of experience respectively. Both participants emphasized that communication is the most critical skill in their profession, with one succinctly stating, "100% of our job is communication." They noted that families often act impulsively during emergencies, misunderstanding the EMTs’ role and, in some cases, verbally or physically assaulting paramedics whom they blame for delays or complications. A common complaint heard from families was, “Where is the trolley? Just carry [the patient],” reflecting a widely held misconception that EMTs are merely transport workers rather than medically trained professionals. These problems were often intensified by cultural norms, miscommunication, and heightened emotional stress during emergencies. The interviewees explained that in the absence of a shared language, they frequently relied on hand signals, body language, and ad hoc interpreters. They identified mental health emergencies as particularly challenging, especially when patients are hysterical or disoriented, requiring EMTs to exercise significant patience and diplomatic communication to de-escalate tense situations. One interviewee shared a particularly illustrative case involving an Indian patient who was found unresponsive in an industrial facility. When EMTs requested assistance from nearby workers to help lift the patient, the bystanders,unaware that the patient had already died,began rubbing his feet in an attempt to revive him, delaying the removal of the body.
The tenth fieldwork visit was conducted at a major EMS facility, where the researcher engaged in a group discussion with EMTs from various nationalities, alongside a Kuwaiti nurse who had ten years of EMS experience. The nurse offered a broader institutional critique of systemic challenges facing EMS professionals in Kuwait. He noted that nurses benefit from union representation and stronger financial incentives, advantages not afforded to EMTs, which contributes to low morale and undermines the attractiveness of the profession. He described how EMTs are often disrespected by both the public and other healthcare professionals, perceived as low-paid laborers whose primary responsibility is to transport patients or equipment, similar to service workers arranging groceries into shopping bags. This lack of public respect was further illustrated by stories of motorists refusing to yield to ambulances, thereby delaying transport and endangering patient outcomes. Families frequently interfered with EMTs’ work; nonetheless, EMTs consistently endeavored to explain procedures clearly to minimize panic and ensure patient safety.
Language barriers remained a recurring theme throughout these discussions. When dealing with patients who spoke neither Arabic nor English, EMTs relied heavily on body language, hand gestures, and ad hoc interpreters. Deaf patients posed particular challenges, as EMTs have not received formal training in sign language. One participant summarized the issue, stating, “We have a problem with deaf people. We wish for training courses. Communication is the most important thing. How do you communicate? Stabilize the case? Control the situation? These are social and specialized skills.”
In addition to language, culturally ingrained practices also interfered with medical care. Some patients or their families employed home remedies that were either medically ineffective or harmful. For example, it was reported that certain individuals applied substances such as coffee, toothpaste, or cigarette ash to burns, practices that complicated proper treatment and wound management.
With these field observations now addressed, the following section will turn to the interviews conducted with female EMTs, allowing for a comparison with the experiences of their male counterparts in the field.
In addition to the on-site field visits, a group of seven female EMTs participated in telephone interviews to share their professional experiences. These participants volunteered and provided consent via one of the social media platforms where the study was advertised, and their identities remain anonymous to ensure privacy and confidentiality. Their work experience ranged from two to nine years. Four of the participants were stationed at a major EMS center located in a remote area, two were assigned to another large EMS facility, and one worked at an EMS training institute. Across these interviews, several key themes consistently emerged, reflecting the interview questions and focusing on EMS resources and staff shortages, English language proficiency, professional challenges, and communication skills.
In comparison to their male counterparts interviewed during the field visits, the female EMTs offered more nuanced and detailed reflections concerning the interpersonal and communicative skills essential for effective patient care. They emphasized that successful paramedic practice requires a combination of strong language and communication abilities, proficiency in both Arabic and English, patience and composure under high-pressure conditions, teamwork, empathy, professionalism in trauma situations, good interpersonal manners, rapid intervention skills, accurate case management. It also requires mastery of fundamental paramedical competencies such as cardiopulmonary resuscitation (CPR), equipment operation, fracture stabilization, airway management, and foreign body removal.
Interestingly, only one of the seven interviewees elaborated specifically on the technical and academic content of their paramedical training programs. The remaining participants concentrated almost entirely on the importance of soft skills and communication, thereby reinforcing the broader finding that non-technical competencies are widely perceived as indispensable in the field of emergency care. Regarding their English language instruction during diploma training, participants reported having completed between two and four courses, covering topics such as medical terminology, conversational English, grammar, reading comprehension, and writing.
Unlike many of the male EMTs interviewed during field visits, most of the female participants expressed general satisfaction with the current availability of ambulances and EMS personnel. Nevertheless, one participant acknowledged that as the EMS system continues to expand with the establishment of new centers, additional staffing and equipment will eventually be required to meet increasing demand.
When discussing language capabilities within the EMS communication system, all female participants confirmed that both Arabic and English were utilized in emergency call centers and during ambulance operations. This observation contrasts with some of the male participants’ perspectives, who expressed uncertainty regarding language practices within the dispatch centers, noting that their contact with call center personnel was limited and that ambulance crews generally prioritized ensuring that at least one team member was fluent in Arabic.
The female participants also identified a range of broader challenges faced by EMTs and paramedics, including communication difficulties with patients from diverse linguistic backgrounds, traffic congestion, interference from uncooperative bystanders, physically demanding work environments, high-stress situations, public misconceptions about EMS roles, and a general lack of public awareness regarding emergency procedures.
Consistently, the female EMTs emphasized the central role of effective communication in ensuring safe and efficient patient care. They underscored that clear communication is essential not only for performing accurate medical procedures but also for de-escalating tense situations, calming distressed patients and family members, fostering trust, and facilitating smooth and safe patient transfers. In their view, communication breakdowns can easily lead to diagnostic errors, procedural delays, unnecessary conflict, and compromised patient safety.
To improve communication practices within EMS, the participants recommended several strategies, including adopting a calm and respectful tone, avoiding confrontational language, offering clear and reassuring explanations to patients and their families, utilizing translation applications or services when necessary, and implementing targeted English language training programs to strengthen EMTs’ proficiency.
In the following section, the primary themes highlighted throughout the study, particularly those emerging from both the fieldwork visits and interviews, will be summarized and analyzed to demonstrate their relevance and effectiveness in addressing the research questions posed in this investigation.
This study investigated the linguistic and sociocultural challenges encountered by Kuwaiti EMTs when responding to emergencies involving non-Arabic-speaking patients. It also examined their preparedness across academic, professional, linguistic, and cultural dimensions. Specifically, the study sought to address two primary research questions: first, what linguistic and sociocultural challenges do EMTs face during emergency interactions with patients, and second, whether EMTs are adequately prepared through their academic training and English language instruction to handle linguistic and sociocultural miscommunications. By employing both quantitative (survey) and qualitative (field interviews) data, several critical themes emerged, many of which align with and expand upon the existing literature.
The key themes highlighted by participants included risks associated with limited English proficiency (LEP), the insufficiency of English instruction in EMS programs, the disruptive role of patients’ families during emergencies, resource and staff shortages, lack of professional recognition, occupational stress, sociocultural misunderstandings, persistent linguistic barriers, and the overarching importance of effective communication.
Survey results demonstrated that although most EMTs self-reported moderate to high levels of English proficiency, significant communication challenges continued to arise in real-world, high-stress emergency situations. These findings are consistent with previous research, which has shown that patients with LEP experience elevated health risks due to communication failures, leading to diagnostic delays, misinterpretation of symptoms, treatment errors, and increased morbidity (Moissac & Bowen, 2018; Perera et al., 2021; Sadaka, 2022).
Participants indicated that the English language instruction received during their diploma programs was often limited in practical value, a finding that mirrors Hidetsugu’s (2012) observation that many paramedic training institutions prioritize general English instruction over English for Medical Purposes (EMP). EMTs in this study strongly expressed the need for communication-focused instruction, particularly emphasizing medical terminology and scenario-based conversational skills, an approach that is widely supported in the literature as critical to patient safety and service quality (Al Shamsi et al., 2020; Flores et al., 2003).
The qualitative interviews provided further depth to these quantitative results, illustrating how EMTs routinely resort to improvised strategies, such as hand gestures, body language, and mobile translation applications, when language barriers emerge. Although these improvisational methods are often necessary, they remain suboptimal. Previous studies have demonstrated that reliance on untrained interpreters or technological tools like Google Translate can lead to serious medical errors, potentially compromising patient safety (Flores, 2006; Moissac & Bowen, 2018).
A recurring challenge emphasized by participants was the frequent interference of patients’ family members, which often obstructed diagnostic procedures and treatment efforts. Families sometimes resisted EMT interventions due to cultural misconceptions, mistrust, or emotional distress,patterns of sociocultural interference that have also been identified by Stadeli et al. (2023) and Whiteside (2022). These barriers are often exacerbated in the absence of robust cultural competence among EMS personnel.
Importantly, the EMTs also described how societal perceptions contribute to occupational stress. The profession is widely misunderstood and undervalued, with EMTs commonly viewed as mere patient transporters rather than frontline medical providers. This public misperception fosters disrespect, diminishes morale, and contributes to high turnover rates within the EMS workforce, challenges that were echoed by Dr. AlShatti in this study and align with broader international research on EMT burnout and job dissatisfaction (Heath, 2023; Karliner et al., 2007).
Cultural and religious sensitivities presented additional challenges, ranging from patients refusing treatment due to gender norms to families relying on harmful traditional remedies such as applying toothpaste, coffee, or cigarette ash to burns. These examples underscore the necessity for EMTs to develop not only linguistic fluency but also cultural competence, a perspective emphasized by Stadeli (2019) and Espinoza and Derrington (2021), who argue that language skills alone are insufficient for establishing trust, building rapport, or making accurate clinical assessments in multicultural contexts.
Suggestions raised by participants, including training EMTs in basic sign language to assist deaf patients, enhancing cultural competency, and strengthening language training, align with existing recommendations in the literature advocating for a more inclusive, linguistically responsive EMS framework (Muller et al., 2020; Mayo Clinic, 2023). Furthermore, as Kuwait’s EMS system advances toward digitalization, international accreditation, and standardized reporting, as noted by Dr. AlShatti, EMTs must also be capable of producing accurate, timely documentation in English, further highlighting the urgency of reforming language instruction within EMS curricula.
The qualitative data strongly affirmed that communication is viewed by EMTs as the core element of their professional practice. As one interviewee aptly remarked, “100% of our job is communication.” This sentiment echoes findings in broader healthcare communication research, which consistently links trust, understanding, and rapport to improved clinical outcomes, reduced risk, and greater patient satisfaction (Flores, 2006; Quan & Lynch, 2010).
All of the questions posed during both the survey and interviews were carefully designed to address the study’s central inquiry into the communication barriers faced by EMTs, whether academic, professional, linguistic, or cultural. The findings reveal that EMTs frequently struggle with public underappreciation of their critical role, facing low wages and limited societal respect despite their responsibility for life-saving interventions. Linguistically, EMTs are continually challenged by Kuwait’s diverse expatriate population, where most EMTs are Arabic-speaking professionals whose English language skills are often limited. Consequently, EMTs are required to demonstrate creativity, empathy, and adaptability when navigating both linguistic and sociocultural differences during high-stakes emergencies. They rely not only on tolerance and interpersonal sensitivity but also on practical tools such as body language, gestures, Google Translate, and assistance from ad hoc translators.
Ultimately, this study underscores the centrality of effective communication within EMS, highlighting that paramedics and EMTs must depend extensively on their communication abilities to accurately assess and treat patients in dynamic and often unpredictable emergency contexts. Linguistic adaptability, cultural sensitivity, and rapid interpersonal responsiveness are not supplementary skills in this field; they are fundamental to ensuring patient safety and delivering high-quality prehospital care.
This research identified several persistent obstacles in EMT-patient interactions, including linguistic barriers, sociocultural misunderstandings, and widespread public misconceptions about EMS, all of which demand immediate attention in terms of training reforms, policy adjustments, and public awareness initiatives. Throughout the study, participants recounted real-life incidents in which communication failures could have led to serious medical consequences. These failures arise not only when EMTs encounter patients who speak unfamiliar languages or have LEP, but even when both parties technically share a language, yet are separated by cultural misunderstandings or differing expectations.
While earlier studies have examined communication between non-Arabic-speaking EMTs and Arabic-speaking patients in Kuwait, this study is among the first to explore the reverse dynamic: Arabic-speaking EMTs interacting with non-Arabic-speaking patients. Given that expatriates constitute the majority of Kuwait’s population, this perspective is particularly important. The study examined EMTs’ linguistic and sociocultural adaptability, assessed the adequacy of their English language training, and documented the communication barriers they regularly encounter.
When linguistic and cultural barriers intersect during time-sensitive emergencies, EMTs must simultaneously demonstrate linguistic fluency, cultural sensitivity, emotional intelligence, and clinical competence. In response to these challenges, EMTs in Kuwait employ a variety of strategies, including translation applications, body language, and bilingual bystanders, to bridge communication gaps and ensure effective patient care. The study reinforces the critical need for improved communication training and enhanced institutional support to ensure that EMTs are fully equipped to deliver life-saving care under increasingly complex conditions.
While the literature contains numerous studies exploring miscommunication in encounters between LEP patients and healthcare providers in English-speaking countries, this study sheds light on LEP EMTs, as well as LEP patients, within the Arabic-speaking context of Kuwait, a country with a substantial expatriate population who often speak neither Arabic nor English. With the exception of Nuguid and Muir’s (2019) qualitative study on interactions between non-Arabic-speaking paramedics and Arabic-speaking patients, there remains a notable gap in research addressing EMT communication barriers in Kuwait and the broader Middle East.
This study also carries several limitations. First, while the survey successfully targeted Kuwaiti EMTs to assess their linguistic and sociocultural adaptability, the field interviews primarily involved non-Kuwaiti EMTs, including Arabs and stateless individuals (Bidoon) born and raised in Kuwait but not legally recognized as Kuwaiti citizens. Second, the data collection coincided with the holy month of Ramadan, a period during which many Kuwaiti EMTs were on vacation and work shifts were shortened, limiting access to participants. Third, the EMS field remains heavily male-dominated, which resulted in the absence of female EMTs during the on-site visits; interviews with female participants were conducted via telephone after one Kuwaiti female EMT discovered the research announcement on social media and shared it with her colleagues. Fourth, some EMS centers were located in remote areas far from urban centers, further complicating field access. Fifth, there is a general scarcity of research on communication barriers within EMS systems in Kuwait and the Middle East. Lastly, while participants were eager to share their experiences, the time constraints and unpredictable nature of EMS work meant that interviews were often brief and conducted under time pressure. Nonetheless, despite these limitations, the participating EMTs demonstrated exceptional professionalism, patience, and honesty in sharing their experiences, challenges, and strategies for maintaining effective communication in the face of extreme pressures.
In light of these findings, several recommendations are proposed to help address the communication barriers that hinder effective EMT-patient interactions. First, as suggested by survey participants, Arabic language courses focusing on basic conversational skills could be offered to non-Arab expatriates residing in Kuwait. Second, English language instruction at the College of Medical Sciences should be revised to emphasize English for Medical Purposes (EMP), rather than general English, as recommended by Hidetsugu (2012). Third, sign language education should be incorporated as an elective in high school or college curricula, or offered as specialized workplace training, to address the unique challenges posed by deaf and hearing-impaired patients. Fourth, there should be widespread societal education and awareness campaigns to promote public understanding of the critical role and professional scope of EMS personnel. Finally, social and cultural sensitivity training should be introduced early in the education system, becoming a mandatory component of school curricula to foster future generations who are globally aware, culturally adaptable, and prepared to navigate the complexities of an increasingly interconnected and diverse world.