This study employed a descriptive phenomenological qualitative design [20]. This approach was chosen to provide deeper insight into the experiences of radiographers employed at the study location while interacting and communicating with patients from diverse cultural and linguistic backgrounds. The research design was applied in two phases:

• Phase 1 explored the radiographers experience in communicating with patients in a multicultural environment in Auckland.
• Phase 2 focused on the development of guidelines. However, this phase will not be discussed in this article.

The Auckland Health Research Ethics Committee (AHREC), University of Auckland, granted ethical approval of the study (reference number AH25471). The following principles were applied to ensure adherence to ethical conduct during the research process [25]:

• Respect for autonomy, right to equality, justice, human dignity and protection against harm [24, 26, 27].
• Right to privacy and confidentiality [28].
• Right to freedom of choice, expression, and access to information.
• Responsiveness to Māori—consultation with Māori was done with the Iwi United Engaged (IUE) [29], who supported the study.

Brief introductions, adequate provision of examination instructions, and clear explanations of what to expect, facilitate a stronger patient-radiographer relationship compared to brief, task-focused imaging encounters [30, 31]. In the current study, participants recalled experiences where the patient generally felt confused and sometimes frustrated throughout the examination, and found it challenging to articulate the type of pain they experienced and follow positioning instructions due to communication breakdown.

I think they feel more confused, especially with, say you're doing a…like a rolled lateral, and you're like feeling on the other side, the patient may not be able to articulate that, oh, it's the left side, or it's the side…. They still don't understand what we're trying to say. [P1].

Sometimes, patients can get a bit frustrated when you can tell that they, they're trying to tell you something and they can't portray it to you… you know that they wanna tell you something, and you wanna understand it, but the communication just isn't there. [P5].

One participant qualified in CT explained the necessity for authorised consent in an immediate emergency, despite the patient's presenting linguistic barriers.

And like sometimes when there's just no way to get anyone to consent the patient in their language, then we just have to get a doctor to, like, do an authorised consent… so in those cases, the patient really doesn't know what is going on at all. [P8].

Participants recalled a time when a Māori patient's previous experiences of personal disempowerment within the public healthcare system negatively influenced future encounters, including their interaction with the practitioners.

… They experienced a bit of racism… I was with another student and she was Māori as well, and we were able to talk to her and kind of help alleviate those, cause she didn't want to come to the hospital. Like she didn't show up for appointments a lot of the time because she didn't wanna experience the same thing. [P6].

On the contrary, adaptations in communication approaches extend beyond linguistic and cultural barriers, encompassing various patient presentations in the radiology department. Patients with intellectual disabilities, such as Down Syndrome, benefit significantly from pronounced facial expressions, intentional verbal and non-verbal cues, variable tones and instructions in plain, simple language [38]. In the current study, the participants' perspectives offered valuable insight into the multifaceted challenges of linguistic and cultural barriers encountered during medical imaging examinations. These reflections reveal a heightened empathy among participants, particularly as they contemplate the often overwhelming feelings of unfamiliarity and anxiety that commonly confront patients upon entering the emergency X-ray department.

I just feel for them even more, cause I'm like, you're probably just as confused as I am… [P9].

Further, it has been shown that patients feel more at ease in communicating their pain levels accurately with healthcare professionals who demonstrate genuine empathy and a sincere commitment to their well-being, ultimately contributing to positive health outcomes [33, 36, 39]. Interestingly, in the current study, participants from various cultural backgrounds empathised with patients, which could have contributed to positive health outcomes in the study location.

It's frustrating at first, but… I feel a little bit more empathetic in that sense, where I'm like, I know I come from a different culture and a different background… And like I just think like, how would I feel if that was my family member? [P9].

The task-driven, fast-paced workplace environment, particularly in ED, influenced participants' adaptations to prioritise efficiency, especially when radiographers faced significant workload pressures during busier shifts. Although research literature signifies the importance of individualised, compassionate patient-centred care [7, 30, 32, 40, 41], participants highlighted substantial challenges tied to patients' presentations, compromised mobility and the severity of language barriers. Further, participants acknowledged the significance of acquiring optimal images and completing examinations, even when faced with perceived barriers.

It's pressuring when you see a patient who speaks a different language because you know that, number one, the patient's probably confused…you want to provide the best, you know, the most diagnostic images and it's just a shame [that] often it's the communication barrier that's limited you from achieving better imaging for the patient. [P4].

Yeah, frustrated… How could they send a patient in that can't communicate without some interpreter for a scan or an x-ray or like, without any information as well? [P2].

In some situations, these communication barriers can have noticeable implications on the procedural workflow and lead to procedures being postponed or cancelled. Radiographers qualified in CT emphasised the non-negotiable nature of patients requiring informed consent for contrast-enhanced CT scans.

We just postpone it until there's like an interpreter or family available… [P8].

…And if they can't give informed consent, again, we can't proceed until they get an interpreter or a doctor to do a consent for them. [P3].

Hence, in the acute clinical setting, patients with linguistic barriers were frequently redirected back to their respective areas within the ED, except in immediate emergencies or resuscitation situations. Further, participants shared experiences that reinforce the substantial consequences caused by communication breakdowns in medical imaging examinations, and they described:

1. The influence of linguistic barriers on patients' presenting clinical indications in the ED following clinical triage.

   A lot of the time, yeah, the doctors and nurses will just send them for x-rays of body parts and only because they've kind of pointed to the area… [P6].

2. Radiographers altered capacity to undergo appropriate clinical decision-making processes.

   … I don't think that it allows for a lot of repeats…it's harder to position the patient accurately if they don't understand what you want, so in a way, you almost allow for a little bit of a greater margin of error… [P5].

3. Patients' misinterpretation of instructions leading up to/during the X-ray examination, causing a greater communication gap between the patient and radiographer.

   It's the changing instructions that I feel like are the biggest reason for repeating…is not being able to explain properly the changing instructions. Like I've had patients that have just put the gown on over the top of their own clothes. [P11].

Participants who could speak the same language spoken by the patients expressed the relief and immediate comfort patients felt when someone in the healthcare setting could understand them. Patients felt the urge to provide more information than needed during the examination.

I feel like they're a lot more, like, grateful when they see someone that they can communicate with properly. [P8].

Sometimes they do give me a little bit too much information that I don't need… [P10].

…and then I just talk to them about, and then I feel like there's already a connection if you just ask them. Then you often get on the topic of, oh, where are you from and stuff like that…And they're a lot… yeah, they're really comfortable. [P6].

In the current study, participants also emphasised the significance of adapting communication strategies in a manner that avoids any condescension or implying that the patient is ‘less intelligent’ simply because a language barrier exists. This insight underscores the importance of preserving the patient's dignity and promoting respectful, patient-centred care during linguistic and cultural interactions.

…also to not assume that the patient is, um, less intelligent. I think sometimes when you, when there's a language barrier, people speak slower, they speak in a different tone, you know?…and I just think, you know, the patient is not less intelligent, they just don't understand your language. [P4].

Recognition and respect for diverse cultural backgrounds, beliefs, and values of patients could enhance the quality of care provided. In the current study, male participants offered valuable insights on the impact of gender in the presence of cultural barriers in patient encounters and the extra care taken to respect female patients' cultural and religious needs to ensure patient comfort.

They have a head scarf and they have specifically asked for a female radiographer… because they do not want to take off the scarf… It's a cultural thing and I totally understand that… [P10].

At the core of radiographers practice lies the paramount importance of individualised patient care and implementing communication strategies tailored to contextual patient factors [13, 30, 40, 45]. However, the study participants perceived that, in certain situations, adopting a more efficient ‘in-and-out’ approach was advantageous, particularly when conducting examinations on patients with limited mobility or those who were unwell in the emergency department or among hospitalised patients. The primary goal of this approach was to mitigate any discomfort experienced by these patients during the imaging procedure. Participants highlighted the following as what contributes to the difference in communication:

1. Patients' perceived mobility status.

ED, I tend to be overly cautious… They don't necessarily have a full medical explanation that's given to you… [P11].

I actually just assume that they're mobile and can move and everything… You find that they're more like, mentally okay. [P11].

2. The inclusion of family members or an interpreter with the capacity to translate.

   I feel like generally when someone comes in out at MSC [outpatient] and they don't speak English normally, they come with a family member. So normally there's someone to translate. [P5].

However, this approach also presented significant limitations as participants pointed out that family members could become emotionally involved in urgent imaging situations, potentially affecting their objectivity. Additionally, there were concerns about the accuracy of relaying sensitive information when family members acted as ‘ad-hoc’ interpreters when no certified interpreters or multilingual staff members were available.

Sometimes it does just make the entire procedure just a bit like messy and chaotic because the family members are sometimes like overbearing… But for the most part, I think family members are great and incredibly patient. [P4].

Further, using family members as ‘ad-hoc’ interpreters has been shown to be less reliable due to their emotional involvement with the patient and the potential to relay sensitive or complex information inaccurately [1, 11, 42]. Contestably, these studies overlook the complexities of the hospital environment from the perspectives of indigenous (Māori) and ethnic minorities in a healthcare system primarily influenced by Westernised culture [35, 36].

3. Patients' familiarity with the examination workflow, for example when they have encountered the imaging process previously.

They've already had their initials in ED to then come as like an inpatient, and then they're an outpatient now… Even if you have a language barrier, at least it's already been introduced to you. [P9].

Several studies mention the general lack of accessibility to professional interpretation services in the hospital [10, 11, 42, 46]. In the current study, participants highly valued effective communication facilitated by a diverse MI team, particularly in the general X-ray department where professional interpreters are not routinely available. Participants were more inclined to ask their multilingual colleagues for interpretation since they were already familiar with the terminology and logistics of the examination, such as confirming patient and referral form details.

If you've got someone like students or, um, qualifieds that speak the same language as the patient, it always helps to get them in. Because they know what they're explaining in terms of like radiography stuff. And then you don't have to wait around for the hospital interpreter. [P2].

We don't have like a translator readily available for all the diverse, like languages we cater to… And it's, we're lucky that we even have a diverse like, um, team that can speak and they can help us in that sense. [P9].

Participants kept meaningful patient interactions at the forefront of their practice. For example, where technological aids (such as Google Translate) were deemed helpful in more profound communication gaps, participants appreciated the seamlessness of incorporating acquired non-verbal cues and visual aids into their examination workflow to convey the same message. This gave them more control over determining what the patient understood, and the demonstrative, abstract nature of general X-ray examination instructions made it easier to physically show the patient what they needed to do.

… it's helpful for, like, explaining what's going on in the moment, but then like, it's quite limited because you can only hold up, you know, your phone in front of them for so long. [P8].

… I haven't done that before. Um, so I find that, using translation like a translator app that does takes up quite a lot of time… And most of the time you can, you can demonstrate what you need them to do. [P10].

Language barriers gets very difficult. I don't trust Google Translate in the slightest. When you start to get to things that are a bit more complicated, it gets really harsh. [P11].

Participants also expressed the usefulness of machines that feature preset voice recordings in common languages spoken by the hospital's diverse patient population. Such machines automatically provided specific instructions (e.g., breathing) in the patient's preferred language, significantly streamlining the examination workflow and ensuring optimal work quality.

Lots of our new CT machines have like built in, you know, breathing or well breathing instructions in different languages… [P4].

In addition, some studies have explored using visual aids in their respective departments to assess patient comprehension and (a) observed a substantial decrease in reject rates after introducing pre-recorded visual instructions accompanied by demonstrative images of examination procedures [47], (b) reported a high response rate from families following the implementation of graphic communication tools, strengthening the connection between healthcare teams and the communities they serve [48]. In the current study, participants exercised their use of non-verbal communication strategies and visual aids in the presence of linguistic barriers to bridge the patient–radiographer communication gap.

So I would just use my hands. I would just tell them to watch me and then I would demonstrate what I will do. It took like twice as long as normal, but that got me diagnostic images regardless. [P9].

He was here for a chest x-ray, so I kind of tapped my chest. Um, and like kind of coughed and looked at him in a questioning way and he nodded his head… [P5].