Lithuanian University of Health Sciences

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Lithuanian University of Health Sciences

Department of Clinical Anesthesiology

“Foreign students: how to manage language differences?”

Author/Student: Imanol García Jover

Supervisor and Consultant: Dr.Andrius Macas

Kaunas 2017/2018

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SUMMARY

Imanol García Jover “Foreign students: how to manage language differences?” Study of difficulties regarding students’ communication in hospital environment, the study is based on foreign students’ experiences in Kaunas hospital. The problem of management language differences is not only based on verbal communication, it is also important to focus on cultural and ethnic differences. The study gathers all these problems, acceptation of foreign students, facilities of communication and barriers that must be broke to get a good diagnosis which is the goal about manage language differences.

Aim: To analyze the basis of the problems of language barrier between foreign speaking medical students and native speaking their colleagues, teachers and patients, learn and understand the protocol and steps to follow in communication with patients speaking different languages.

Objectives: 1. To analyze problems with communication (teachers help, work environment, facilities from university) from foreign students in Lithuania

2. To assess future doctors how to communicate with a patient who speaks different language.

Methods: A questionnaire (annex 1) was made to 71 foreign students (30 women 42.3% and 41 men 57.7%) from different countries and ages, who are studying in Lithuanian University of Health Sciences (LUHS) 6th year, regarding different items involving working environment, knowledge of foreign language (Lithuanian) and help from the university, the questionnaire was sent to each of them via email (Google Forms), and the answers are anonymous. The method used to gather and express in the graphics all the results was a descriptive statistics method.

Study participants: student: Imanol García Jover; supervisor: Dr.Andrius Macas; -consultant: Dr.Andrius Macas; - 71 6th year foreign students (30women, 41men)

Results: The students’ opinion show, that communication with patients in our hospital is good enough but some measures need to be taken for improvement.

Conclusions: According to performed study great part of foreign students face language difficulties. According to our experience factors which could affect the change where initial language studies, possibility to get familiar with study program in English and Lithuanian in order to facilitate the work on hospital, instructions to the teachers on students necessities and provide an environment of mutual respect, as well as teach students not just verbal communication but also skills how to treat people from different age and culture.

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SANTRAUKA

Imanol García Jover “Užsienio studentai: kaip įveikti kalbos skirtumus?”

Tyrimas apie studentų bendravimo ligoninės aplinkoje sunkumus pagrįstas užsienio studentų patirtimi Kauno ligoninėje. Kalbų skirtumų suvaldymo problema pagrįsta ne tik verbaliniu bendravimu, taip pat svarbu atkreiptį dėmesį į kultūrinius ir etninius skirtumus. Tyrime aptariami visi paminėti šios problemos aspektai- užsienio studentų priėmimas, komunikacijos galimybės ir kliūtys, kurias reikia pašalinti , siekiant gauti gerą diagnozę, kurios tikslas - įveikti kalbos skirtumus.

Tikslas: išanalizuoti kalbos barjero problemą tarp užsienio kalba kalbančių medicinos studentų ir jų kolegų lietuvių, dėstytojų ir pacientų, mokytis ir suprasti protokolą bei veiksmus, kurių reikia laikytis bendraujant su skirtingas kalbas vartojančiais pacientais.

Uždaviniai: 1 .Išanalizuoti užsienio studentų komunikacijos problemas Lietuvoje ( dėstytojų pagalba, darbo aplinka, universiteto galimybės) ir rasti jų sprendimo būdus remiantis kitų šalių patirtimi ir pavyzdžiais.

2. Įvertinti būsimus gydytojus, kaip jie pasiruošę bendrauti su pacientu, kuris kalba kita kalba.

Metodas: klausimynas (1 priedas) buvo pateiktas 71 užsienio studentui (30 moterų 42,3% ir 41 vyrui 57,7%) iš skirtingų šalių, skirtingo amžiaus, kurie šeštus metus studijuoja Lietuvos Sveikatos Mokslų Universitete (LSMU). Klausimyne buvo pateikti įvairūs klausimai susiję su darbo aplinka, užsienio kalbos žiniomis (lietuvių kalba), universiteto pagalba. Klausimynas buvo išsiųstas kiekvienam iš respondentų elektroniniu paštu (Google Forms), atsakymai yra anoniminiai. Aprašomasis statistinis metodas.

Tyrimo dalyviai: -studentas: Imanol García Jover; -vadovas: Dr.Andrius Macas; - konsultantas: Dr.Andrius Macas; - 71 šeštus metus studijuojantis užsienio studentas (30 moterų, 41 vyras).

Rezultatai: Studentų nuomonė rodo, kad bendravimas su pacientais mūsų ligoninėje yra pakankamai geras, tačiau reikia tobulinti kai kurias priemones.

Išvados: Pagal atliktą tyrimą didelė dalis užsienio studentų susiduria su kalbų skirtumų sunkumais. Remiantis mūsų patirtimi, išskyrėme šiuos veiksnius, galinčius turėti įtakos pokyčiams: pradinės kalbos studijos, galimybė susipažinti su studijų programa anglų ir lietuvių kalbomis, kad būtų lengviau dirbti ligoninėje, instrukcijos dėstytojams apie studentų poreikius, abipusės pagarbos aplinkos sukūrimas, studentų mokymas ne tik žodžiu, bet ir įgūdžių lavinimas, kaip elgtis su skirtingo amžiaus ir kultūros žmonėmis.

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ACKNOWLEDGEMENTS

This research is a part of my integrated studies in the Lithuanian University of Health Sciences as a Final Master Thesis, during my 5 th and 6th years of medical studies.

I would like to thank personally supervisor Dr. Andrius Macas who helped, taught and advised me throughout the whole research work.

CONFLICT OF INTEREST

The author reports no conflict of interest.

CLEARANCE ISSUED BY ETHICS COMMITTEE

Title: Foreign students: how to manage language differences?

Date of issue: 2017-10-11. Number: BEC-MF-44.

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ABBREVIATIONS

CAT- Communication Accommodation Theory.

LUHS- Lithuanian University of Health Sciences.

ICU- Intensive Care Unit.

WSU- Washington State University.

PUC- Catholic University of Chile.

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TERMS

Acclimatization: to adapt or become accustomed to a new climate or environment.

Behavior: the way in which one acts or conducts oneself, especially towards others.

Collaboration: the situation of two or more people working together to create or achieve the same thing.

Communication skills: the ability to convey or share ideas and feelings effectively.

Doctor-patient communication: the verbal interaction that is established between the doctor and the patient during the course of the disease.

Language: the method of human communication, either spoken or written, consisting of the use of words in a structured and conventional way.

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INTRODUCTION

The main problem in communication of doctor and patient from different countries is language. Other different factors as acclimatization, relationship, skills, behavior and collaboration between doctor and patient, are also essential to achieve a good communication.

This research shows how confidence can falter on facing that moment, speaking. Some students will need more help with the linguistic challenges faced during their degree, particularly during their first year. As a consequence, teachers need support also, to ensure that they are aware of potential problems and how to identify them.

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AIM AND OBJECTIVES OF THE THESIS

Aim: To analyze the basis of the problems of language barrier between foreign speaking medical students and native speaking their colleagues, teachers and patients, learn and understand the protocol and steps to follow in communication with patients speaking different languages.

Objectives: 1. To analyze problems with communication (teachers help, work environment, facilities from university) from foreign students in Lithuania

2. To assess future doctors how to communicate with a patient who speaks different language.

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LITERATURE REVIEW

The base of good communication between doctor and patient is not only knowledge of the language (language barriers). Other facts like acclimatization, relationship, skills, behavior and collaboration, are essential to resolve the main problem (foreign student-native patient communication) [1].

Communication statements according to Dr. Suzanne Kurtz from Washington State University (WSU), Dr. Gricelda Gómez and Dr. Philippa Moore from Catholic University of Chile (PUC) [2, 3]:

 Communication is an aptitude necessary for clinical practice.

 Communication has been practiced from the moment of birth.

 Communication skills learned in his/her life before entering medical school require adaptation for the doctor-patient relationship.

 Communication is learned with students’ practice at medical school.

 Doctors do not get to be an "expert" in communication.

 Communication in medicine is a series of skills learned.

 It is not a personality feature.

 Everyone can learn.

 It requires a formal education.

 The only experience is usually a bad teacher.

 It requires a theoretical-practical, didactic-experiential teaching.

 Knowledge of skills does not translate directly into execution or action.

 Reflecting through a specific feedback on their observable behavior allows the student to realize, recognize and improve his / her related competence.

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11 Recommendations for communication teaching, according to Dr. Ruiz-Moral from National University of Cordoba (UNC) [4, 5]:

 A education with clear objectives, structure and developed following a program starting from the basic knowledge to the most complex.

 Teaching in a environment of mutual respect with small groups of students, where they can expose their significant problems. Teaching should be based on adult learning principles focus on students that leads to assess the students by themselves.

 Methodologies based on interaction and experiences for students.

 Observation of students’ actions using simulated and real patients.

 Evaluation, correction and help on observed skills.

 Final evaluation should include observation of student-patient interviews.

 Teachers with experience teaching small groups.

 Allowing teacher modeling and student practice of communication skills during clinical rotations.

 Adequate support for teachers who teach communication.

 The continuous teaching in communication should be evaluated periodically.

Doctor-patient communication [6, 7]:

Communication is a fundamental point in the practice of medicine, is maybe the most important part of our work.

Good communication is also a standard of quality of care. The chance of conflicts is higher, if communication is deficient in somehow. And it is well known that above malpractice or organizational issues, most of complaints that occur in the health field are related to doctors’ behavior, attitude or communication.

The expressiveness of emotions is some of the aspects that influence the health essence. Sick people and their relatives could feel uncertain, be afraid, anxious etc. effective communication can be interfered by a whole series of emotions and make the messages do not arrive as expected. Also there is a group of cultural and educational aspects that are not always perceived and both (doctor and patient) must to respect to neither interfere in communication.

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12 In a emergency situation when we don’t know the patient or family, we must be able to understand the characteristics of the patient who we are going to take care of and how the family acts in this situations, how they express themselves, and in this more or less stressful moment how they handle emotions, all this procedure we have to understand it in a few minutes.

Language: The language is the key to get a good doctor-patient communication. In the case of foreign language we should try to using other words to express ourselves to make the patient feel confident and make sure that he or she understand what we are explaining [8].

Language barriers according to Segalowitz and Kehayia [9]: The communication problems, arise from language differences, to understand it, three theoretical approaches show it. The first one is a psycholinguistic approach, focused on the way in which speakers using semantic and syntactic elements of the language to conform a appropriate message, direct the receptor attention on the main information from the message, and on the capacity from this person to interpret the intention of the speaker. Interactions during patient-doctor conversation, consist the second theoretical approach [10]. This approach is focused in how language use present power differences in relation between doctor and patient. The third theoretical approach, the framework of Communication Accommodation Theory (CAT) [11, 12].CAT proposes that: 1- speakers try to change (or not) their speaking mores, to achieve important social goals; 2- the degree to which speaker presents the need for communication efficiency; 3- convergence is viewed as positive and normative; and 4- divergence in manner of speaking display a specific intention to do so, and is normally perceived negatively. CAT thus provides a useful framework for examining the dynamics of patient-doctor communication, especially when at least one of the speakers uses a second language. In such cases, an inability to achieve convergence can affect how the speakers perceive not only each other, but also the quality of the working relationship between them [13, 14, 15].

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13 Acclimatization:

To adapt or become accustomed to a new climate or environment [16].

The acclimatization process is very important regarding wellbeing of the person in the foreign country. The time needed to get acclimated, differs among people. Acclimatization will be easier for foreigners coming from countries with similar weather conditions and habits. In the case of Lithuania, regarding weather acclimatization will be easier for foreigners coming from countries with low winter temperatures like Sweden, Poland etc. In this case those students will get comfortable sooner comparing with foreigners coming from countries with wormer temperatures like Spain, Israel, Lebanon, etc. In case of culture, to have an open mind and understand different people manners are essential to find the correct way to communicate with them. Accept and understand different people manners will make easier and faster the acclimatization. Is much easier to get acclimatized with help from native people, they can teach you their living habits, personality and culture to speed the process.

Communication skills:

Comprehensive patient care, tend to lose importance in doctors training, and also declination in communication skills as students progress through their medical education is usual. During internship and residency the emotional and physical brutality of medical training, changes talking with patient for procedures and techniques, suppresses empathy, and could even result in contempt of patients [17].

Behavior:

The distress that provoke, the incapacity from a doctor to handle a discussion of social and emotional impact with patients, or because they did not have time to do it appropriately, lead to avoidance of the discussion. Situations like this, produce a negative emotional repercussion to doctors, and tend to increase patients distress. This avoidance behavior may result in patients being unwilling to reveal problems, which could delay and adversely impact their recovery [18].

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14 Collaboration: The courage to expose of complains, expectations and concerns as well as request for information from patient to doctor, is essential to achieve good communicative relationship between patient and doctor from patients. The negative influence of doctor´s attitude can result in a deterioration of doctor-patient communication, increasing patients need for information and explanations. Patients could be unable to accomplish their health goals because they may feel disempowered. Poor patient understanding is the result of lack of sufficient explanation, and a lack of agreement between doctor and patient can lead to therapeutic failure [17].

Specific problem - foreign student and native patient:

Effective doctor-patient communication is essential for delivering quality healthcare [19]. Nevertheless, language barriers remain some of the most reported hindrances that physicians need to overcome in a healthcare setting [20]

.

The main problem that we need to solve with the following study is the communication between a foreign student and native patient. All the concepts described are the key to solve this problem, but won’t be always useful because each person have a way to express and to treat with people.

The problem of communication does not depend just on carry out all this concepts, in our case in Lithuania a foreign student have also the difficulty of learning two different languages one to complete the studies and other to communicate with patients, this makes even harder the way to express with the correct words and manners as the student will do in his/her native language.

The basic problem of the foreign student as I mentioned is language, with knowing it a big step is done because is the base of communication, but other problems can happen, when a student tries to communicate with a native patient, ethnical problems are one of the reasons that good communication can’t occur in all countries, to achieve a proper way to communicate between foreign student and a native patients is important the acceptation from a native person that a foreigner with different color of skin, language and culture is going to treat him/her, also sex differences, a person from different sex has to be treated equally as a one from the same sex of the patient.

All these problems can be fixed with the help of a native teacher, who must to promote an atmosphere of mutual respect, have good communication and mentoring skills and help the student when he/she does not understand patients.

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RESEARCH METHODOLOGY AND METHODS

The aim of this work is to analyze the basis of the problems of language barrier between foreign speaking medical students and native speaking their colleagues, teachers and patients, learn and understand the protocol and steps to follow in communication with patients speaking different languages.

In a foreign country where you are going to work, to understand the language is essential for communication. Specially, doctors who have to communicate with patients need to understand them to provide a correct diagnosis and treatment. In our university the problem with communication is higher than in other universities, because a lot of students, who come to Lithuania, do not have a good level of English making even harder to express themselves and to communicate with native people. Also as we are a multicultural university there are different barriers that need to be cross to get a good communication with patients as: culture, race, fear and embarrassment. Work environment is also very important for foreign residents, in a working environment where native colleagues and doctors helps you with the language makes easier to work and improve.

To evaluate these difficulties in our hospitals in Kaunas, a questionnaire (annex 1) was sent to 71 foreign students (30 women 42.3% and 41 men 57.7%) from different countries and ages, who are studying in Lithuanian University of Health Sciences (LUHS) 6th year, regarding different items involving working environment, knowledge of foreign language (Lithuanian) and help from the university, the questionnaire was sent to each of them via email, and the answers are anonymous and the method used to interpret all the gathered information was a descriptive statistics method.

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RESULTS

The results were obtained making graphics regarding answers of questionnaire (annex 1) from 71 students 30 women (42.3%) and 41 men (57.7%) [Fig.1], from 15 different countries [Fig. 2] studying at LSMU 6th year, using a descriptive statistics method.

Fig. 1. Graphic questionnaire (GENDER)

Fig. 2. Graphic questionnaire (NATIONALITY)

The students’ opinion show, that communication with patients in our hospital is good enough but some measures need to be taken for improvement.

The students where asked about information of the university given before start working in hospitals(There is access to an educational program relevant to my needs?) 85.9% YES over 14.1% NO [Fig. 3] answer that there is access for this information, also was asked if the information was given in our studying language (English) 87.3% YES over 12.7% NO [Fig. 4] answer that this information is in English which makes easier to understand how

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17 we should proceed in hospitals, their opinion about if the hospital have good quality accommodation for them 73.2% YES over 16.8% NO [Fig. 5], and finally if they have enough clinical learning opportunities, 69% YES over 31% NO [Fig. 6], this four questions were asked regarding the facilities and help provided by the university showing that the most important point to improve is the accommodation and clinical learning for students in hospital.

Fig. 3. Graphic questionnaire (EDUCATIONAL PROGRAM)

Fig. 4. Graphic questionnaire (EDUCATIONAL PROGRAM LANGUAGE)

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Fig. 6. Graphic questionnaire (CLINICAL LEARNING)

Questions about preparation of students regarding knowledge language (Lithuanian) were asked, one before start working in hospital showing that more than the half 64.8% YES did studied the language over 35.2% NO [Fig. 7] who did not, and other about extra support at hospital showing the same statistics 64.8% YES over 35.2% NO [Fig. 8] are getting extra support, this two items show that same percentile of students who studied the language do need extra support at work

Fig. 7. Graphic questionnaire (LANGUAGE BEFORE WORKING)

Fig. 8. Graphic questionnaire (EXTRA SUPPORT)

Other important questions were asked regarding racism and sexism, two items very important for a foreigner who will have constant contact with native people, the results of the questionnaire shows that 84.5% NO of the people asked, thinks that there is not racism in

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19 hospitals, over 15.5% YES [Fig. 9] who thinks or suffer it, and 69% NO thinks that there is not sex discrimination, over 31% YES [Fig. 10], who thinks or suffer from it.

Fig. 9. Graphic questionnaire (RACISM).

Fig. 10. Graphic questionnaire (SEXISM)

This results, shows that in our hospital there is not a big problem with racism, in case of sex discrimination 31% of the students think that there are some differences between sexes. This problem does not have direct effect on communication with patients but it have repercussions of predisposition from patients or other doctors on listen or have on count the opinion and knowledge of the student.

A very important point to study is the opinion of the students from teachers, because the help and instruction that they provide to the students, is essential to achieve a good environment at the working field and facilities communication with patients. Five questions were given to evaluate it. The first and second questions were concerning teachers skills, communication 69% YES over 31% NO [Fig. 11] and mentoring 77.5% YES over 22.5% NO [Fig. 12], displaying that the students think that teachers have good communication and mentoring skills. The following three questions were asked to evaluate the teachers help at working field, if they help students with language (Lithuanian), 88.7% YES over 11.3% NO [Fig. 13], if promote an atmosphere of mutual respect, 93% YES over 7% NO [Fig. 14], and if they provide students a good feedback on strengths and weaknesses 70.4% YES over 29.6% NO [Fig. 15], this results indicate that the students are getting as many as required help but will need some support which will motivate them to work with more interest.

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Fig. 11. Graphic questionnaire (COMMUNICATION SKILLS)

Fig. 12. Graphic questionnaire (MENTORING SKILLS)

Fig. 13. Graphic questionnaire (HELP WITH LANGUAGE (LITHUANIAN))

Fig. 14. Graphic questionnaire (ATMOSPHERE OF MUTUAL RESPECT)

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Fig. 15. Graphic questionnaire (GOOD FEEDBACK)

Questions regarding students’ feelings at working field were also asked to evaluate the comfort which is very important to aim an adequate environment that makes easier the communication with patients. Those questions are: There is no-blame culture in hospital? 85.9% YES over 14.1% NO [Fig. 16], I am bleeped inappropriately? 97.2% YES over 2.8% NO [Fig. 17], I feel physically safe within the hospital environment? 100% YES over 0% NO [Fig. 18], the opinion of the students shows that this problems are not present in the hospital. Feelings of students with in class/working environment were also questioned, to evaluate the integration and enjoyment during work. I feel part of a team working here? 78.9% YES over 21.1% NO [Fig. 19]. I get a lot of enjoyment out of class? 52.1% YES over 47.9% NO [Fig. 20]. This results tells us that the students are integrated with doctors at work but just the half of them enjoy this time working in hospitals.

Fig. 16. Graphic questionnaire (NO BLAME CULTURRE)

Fig. 17. Graphic questionnaire (BLEEPED INAPPROPRIATELY)

Fig. 18. Graphic questionnaire (PHYSICALLY SAFE)

I

feel physically safe within the hospital environment

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Fig. 19. Graphic questionnaire (PART OF A TEAM)

Fig. 20. Graphic questionnaire (ENJOYMENT OUT OF CLASS)

As this thesis is made with the supervision of Anesthesiology Department, questions concerning surgery studies and difficulties working in this department according language differences were also asked. According language differences, is it easier to work in therapy or surgery fields? 81.7% surgery studies over 19.3% therapy studies [Fig. 21]. According language differences I find less difficulties working in anesthesiology department? 70.4% YES over 29.6% NO [Fig. 22]. I find that working in ICU (Intensive Care Unit) requires more knowledge of the language 81.7% YES over 19.3% NO, this results indicates that it is easier to work and communicate in surgery studies at Anesthesiology Department.

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Fig. 22. Graphic questionnaire (DIFFICULTIES ANESTHESIOLOGY DEPARTMENT)

Fig. 23.Graphic questionnaire (ICU KNOWLEDGE OF LANGUAGE)

Finally, we asked the students to give some recommendations for future students in LUHS. Most suggestions included learning Lithuanian before working and trying to do your best. Recommendations for future students in our hospitals (10 answers):

• Learn language before working in hospital. (3) • Learn language during practical classes.

• Learn language at hospital environment not at class.(2) • Empathy.

• Try your best and actually study for Lithuanian classes. • Learn Lithuanian.

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DISCUSSION OF THE RESULTS

The comparison of the results between our and other studies was very complicated because it was difficult to find any other studies about this particular issue. There are some studies regarding the importance of doctor-patient communication, relationship and other facts important to the practice of medicine, and other articles and studies regarding the difficulties of communication between foreign students, but not about foreign students and how to manage language differences in medical practice.

We noticed that different important points are needed to be followed to achieve the best possible communication between students and patients in our university:

- To learn the useful medical language before starting medical practice, this is very important because if the student knows the language properly before start working communication will be easier to achieve.

- Students program should be provided in both English and Lithuanian languages. - To instruct the teachers on students necessities (working politely, avoid sexism or racism abuse, help student with the language problems speaking with patients, etc.) and provide an environment of mutual respect.

- To teach student not only verbal communication with patients also skills and how to treat people from different ages and culture.

During our study we noticed, that it is very important that teachers provide feedback on their experiences, examples of good practice, if their observations are heard and acted by students. We can enable international students to work by themselves, only when both students and teaching doctors are fully supported

.

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CONCLUSIONS

According to performed study great part of foreign students face language difficulties. According to our experience factors which could affect the change where initial language studies, possibility to get familiar with study program in English and Lithuanian in order to facilitate the work on hospital, instructions to the teachers on students necessities and provide an environment of mutual respect, as well as teach students not just verbal communication but also skills how to treat people from different age and culture.

The study also shows that students find easier to work in surgical practice and anesthesiology departments, this means that communication with patients in anesthesiology department, is easier, and also teachers in this department are well prepared to instruct students and help them with communication troubles.

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ANNEXES

Annex 1: Questionnaire

Dear students, this questionnaire aims to clarify addaptation and enviromental

situation of foreing students in hospital. The questionnaire is anonymous. For each question, select / type the appropriate option. (Y) yes (N) no

1. Your gender: Male/Female 2. Age...

3. Where were you born?……… 4. Time “working” in hospital (months)……….

5. I learned the language before start working in hospital: Y/N 6. I’m getting extra support with the language at work: Y/N

7. There is access to an educational program relevant to my needs: Y/N 8. I had an informative induction program in my language: Y/N

9. My clinical teachers help me when I don’t understand patients: Y/N 10. My clinical teachers have good communication skills: Y/N

11. My clinical teachers promote an atmosphere of mutual respect: Y/N 12. I feel part of a team working here: Y/N

13. I have enough clinical learning opportunities for my needs: Y/N

14. My clinical teachers provide me with good feedback on my strengths and weaknesses: Y/N

15. There is racism in hospital (teachers, classmates, patients): Y/N 16. I am bleeped inappropriately : Y/N

17. There is sex discrimination in hospital (teachers, classmates): Y/N 18. This hospital has good quality accommodation for students: Y/N 19. I feel physically safe within the hospital environment: Y/N

20. There is a no-blame culture in hospital: Y/N

21. My clinical teachers have good mentoring skills: Y/N 22. I get a lot of enjoyment out of class: Y/N

23. According to language differences, is easier to “work” in: surgery studies/ therapy studies

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29 24. According to language differences, I find less difficulties “working” in

anesthesiology department: Y/N

25. I find that “working” in ICU(intensive care unit) requires more knowledge of language: Y/N

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30 Annex 2: Copy from Clearance Issued by Bioethics Committee

Lithuanian University of Health Sciences