Pacific nurses’ experiences of informal interpreting and language assistance in healthcare settings in Aotearoa New Zealand: results of an alumni survey

Effective communication between patients and clinicians in a shared language is critical for safety and positive health outcomes.¹ Research from English-speaking countries demonstrates that patients with limited English proficiency (LEP) face barriers to accessing services, incomplete information transfer, reduced understanding of medical care, less effective self-management and longer or additional follow-up consultations.¹

In Aotearoa New Zealand, for example, research with Pacific mothers has highlighted that those who speak Pacific languages at home are significantly less likely to receive or act on safe sleep information, pointing to system-level communication failures within mainstream services and underscoring the need for linguistically aligned communication within the health system.²

The New Zealand Code of Health and Disability Services Consumers’ Rights³ guarantees the right to a competent healthcare interpreter,⁴ while the Health Practitioners Competence Assurance Act 2003 mandates cultural safety standards, including effective communication.⁵ Consistent with global literature, professionally trained and, where applicable, certified in-person interpreters are considered the gold standard for addressing patient–clinician language discordance.⁶ However, untrained interpreters are often being utilised instead.^7–9 The reasons for the reliance on untrained interpreters include budget constraints; workforce shortages, particularly for Pacific languages with low diffusion; and the dynamic nature of healthcare, where pre-planning for interpreters is not always feasible. International literature has documented how clinicians and health workers navigate language barriers,^10,11 often relying on family members or untrained bilingual staff and facing structural constraints in accessing professional interpreters.¹² Aotearoa New Zealand research similarly shows that even when clinicians recognise the risks of poor communication associated with LEP patients, trained interpreters are under-utilised.¹³ Although there is substantial qualitative research in this area,¹⁴ little work has examined how often nurses themselves are called upon to interpret, and almost none has explored this in Pacific or Aotearoa New Zealand contexts.

Aotearoa New Zealand has a limited tradition of integrating Pacific language interpreting services into public healthcare,⁴ compounded by insufficient data on the number of LEP individuals or those requiring interpreters.⁸ Pacific peoples, the fourth largest ethnic group in Aotearoa New Zealand, make up approximately 9% of the national population¹⁵ and encompass over 17 distinct ethnic, cultural and linguistic communities. Two-thirds of Pacific peoples are Aotearoa New Zealand–born, with 25% identifying with multiple ethnicities. Among overseas-born Pacific peoples, 46% have resided in Aotearoa New Zealand for over 30 years.¹⁶

An immigration survey (2005–2009) found that Pacific migrants had significantly lower English proficiency than non-Pacific migrants, with only 38% reporting English as the language they spoke best, compared with 62% of non-Pacific migrants.¹⁷ English proficiency varied widely: 58% of Fijian migrants reported English as their best language, compared to 16% of Samoans and 20% of Tongans. The 2018 Census indicated 92% of Pacific people spoke English, leaving 8% (33,684 individuals) who did not.¹⁸ The ability to speak Pacific languages varied among groups, ranging from 9% who spoke Cook Island Māori to 50% who spoke Samoan.¹⁹ However, the accuracy of these findings is limited by a 65% census response rate, which is skewed toward Aotearoa New Zealand–born, English-speaking individuals, likely leading to an under-estimation of language proficiencies.²⁰

In 2023, Pacific nurses represented 4% (2,722) of Aotearoa New Zealand’s nursing workforce.²¹ Ethnic composition included Fijian (32%), Samoan (31%), Tongan (18%), Niuean (5%) and Tokelauan (4%). Most Pacific nurses trained in Aotearoa New Zealand, while 17% trained overseas, primarily in Pacific countries.²² This study reports on nurses’ experiences providing informal language assistance to Pacific patients and families with LEP in healthcare settings.

Methods

Study design and setting

This cross-sectional study was conducted using an online survey. Data were collected between 9 October and 27 November 2023. This research is part of a broader evaluation of the first 11 years of the Aniva Pacific Workforce and Leadership Development Programme (Aniva) for Pacific nurses in Aotearoa New Zealand.²³ Funded by Health New Zealand – Te Whatu Ora (HNZ) and delivered through Whitireia Polytechnic by Pacific Perspectives Ltd (an independent Pacific health provider), the primary strategic goal of the programme is to significantly increase the number of Pacific nurses and midwives holding postgraduate qualifications in Pacific health leadership, thereby preparing them for leadership roles within the health sector. The Aniva programme offers New Zealand Qualification Authority (NZQA)–approved qualifications including a Postgraduate Certificate and Diploma (Pacific Health), and a Master of Professional Practice (Leadership).

Ethics

This study received approval from the Te Pukenga—Whitireia and Weltec Ethics and Research Committee (RP 483—2025).

Recruitment and data collection

The survey was open to all 229 individuals who had previously enrolled in the Aniva programme. While this group included a small number of midwives, the vast majority were registered nurses. Therefore, for clarity and consistency, we refer to participants collectively as “nurses” throughout this article. Recruitment was conducted via email invitations using contact details in the Aniva administrative database. Reminder emails and follow-up phone calls were used to boost response rates. As an incentive, all nurses who completed the survey were entered into a draw to win one of 10 grocery vouchers. The survey was administered using Jotform, a Cloud-based online survey platform (Jotform Inc., San Francisco, California, United States of America), selected for its user-friendly interface. Responses were exported into Microsoft Excel (version 16) for data management and descriptive analysis.

Questionnaire

The questionnaire comprised 104 questions (Appendix Table 1), predominantly closed-ended with some open-ended prompts, covering demographics, experiences with the Aniva programme, qualifications and alumni work roles. Demographic questions were aligned with the Te Kaunihera Tapuhi o Aotearoa | Nursing Council of New Zealand tracking survey. This article focusses on responses to questions 20–24 regarding Pacific languages and interpreting in the workplace, with additional insight from an open-ended question (question 25). The questionnaire was developed by the research team (DR, DN, SF, AV, AS, HK, GS) drawing on their practical and academic experiences in education, nursing workforce development and Pacific health, and piloted among the first 20 alumni. 

Analysis of quantitative data

Descriptive statistics and Chi-squared tests were used to summarise participants' characteristics and asses participation-related associations. To evaluate potential response bias, we compared the demographic and professional characteristics available in the Aniva administrative dataset between respondents and non-respondents. Logistic regression identified factors linked to confidence and training in interpreting or translation tasks. Analyses were conducted using R version 4.2.2 (R Foundation for Statistical Computing, Vienna, Austria) and IBM SPSS Statistics version 29.0.2.0 (IBM Corp., Armonk, New York, United States of America).

Analysis of the free-text responses

The open-ended (question 25) responses provided insights into participants’ experiences. Framework analysis, a systematic qualitative method, was chosen to enhance rigour and transparency when working with this multidisciplinary team and large dataset.²⁴ This method involved two main stages and five steps: stage one was creating an analytical framework and stage two was applying this framework to the dataset. The five steps were: 1) familiarisation with responses, 2) development of a coding framework (informed by both the survey topics and an initial scan of the free-text answers), 3) indexing data to codes (applying the coding framework), 4) charting coded responses into a matrix (summarised text entered into cells) and 5) mapping and interpretation (finding patterns, clarifying concepts, developing themes). This approach facilitated the identification of patterns, comparisons and variation across the free-text dataset, leading to themes beyond the predefined closed question responses. Coding was performed independently by two researchers (DR and TT). Discrepancies were resolved through discussion with other team members (GS, HK, AA, SF, AS) at regular team meetings, enhancing the rigour and consistency of the analysis.

Results

The response rate for the survey was 69% (159/229). Respondents were more likely than non-responders to be younger (χ²=14.22, df=3, p=0.0026), born in Aotearoa New Zealand (χ²=8.35, df=1, p=0.0039) and of Samoan descent (χ²=7.19, df=1, p=0.0073). They were also more likely to be enrolled more recently in Aniva (χ²=41.76, df=2, p<0.0001) and to have been more recently registered as nurses (χ²=4.58, df=1, p=0.0324). In contrast, city/region of residence, gender, Pacific ethnicity other than Samoan descent, country of birth within Pacific sub-groups, country of citizenship and country of residence showed no significant association with survey response (all p>0.05).

Quantitative findings

The characteristics of the 159 respondents are shown in Table 1. The majority were female (91%), aged between 36 and 65 years (83%), and over half (52%) were born in a Pacific country. Most overseas-born respondents had migrated to Aotearoa New Zealand in the past 25 years, or since the 2000s (39%), followed by the 1990s (20%) and 1980s (13%).

Eighty percent (127) of respondents spoke a Pacific language, and 46% reported that it was their first language. The most spoken languages were Samoan (45%), Tongan (20%) and Fijian (17%). Among these, 113 (91%) spoke one Pacific language, 12 (9%) spoke two, and two spoke three Pacific languages (data not shown).

View Table 1–3.

Of the 127 respondents who spoke a Pacific language, 120 answered questions about language use at work (questions 21–25). Of these, 118 (98%) reported using their Pacific language in the workplace, and 102 (85%) indicated that they had received requests to translate or interpret for patients and families in other areas of the workplace. Requests for assistance with interpreting or translating were made by colleagues (89%), patients and families (75%), and supervisors or managers (64%); 51% had been asked by all three groups. The majority of respondents (75%) reported feeling confident and possessing the skills to provide this assistance (Table 2). Confidence with interpreting or translating appeared higher among older participants, Fijian speakers and those with a Pacific first-language; however, none of these associations reached statistical significance (all odds ratios [ORs] 1.6–3.5, all p>0.05). By contrast, being born in a Pacific country was a statistically significant predictor (OR 3.2, 95% CI 1.3–8.1, p=0.015).

Qualitative findings

The open-ended prompt (question 25) yielded 101 free-text responses. Of these, 115 useable quotes were identified, systematically coded and charted using the predefined thematic framework. The analysis resulted in three main themes and nine sub-themes, which are summarised in Table 3 and elaborated below with representative participant quotes.

Theme one: nurses’ linguistic and professional capabilities

Respondents frequently reported high levels of confidence in their interpreting abilities, often attributing this to fluency in Pacific language(s), prior training and personal backgrounds including upbringing in traditional church settings.

 “I am fluent in Samoan and confident to interpret for clients/families.”

“I am a confident Fijian speaker, and I speak two different types of Fijian language.”

“…growing up in a Niuean traditional church, taught me to vagahau Niue [the Niuean language], I was happy to [interpret].”

Nurses reported being comfortable using their Pacific language for general conversations, but for many, there were challenges with formal language and technical medical terminology lacking direct Pacific translations, such as anatomical terms.

“When it comes to organs in the body and the science … it’s very hard to explain or even know what those organs are called.”

Despite these challenges, interpreting was consistently described as “rewarding” and “gratifying”, driven by cultural values like tautua (service) and a desire to “give back to my community”. Many viewed language support as central to their professional and cultural identity. Nurses drew on their clinical expertise and cultural insights to translate complex clinical details, employing diagrams and culturally relevant metaphors, for example, using Lali (Fijian) drumbeats to explain atrial fibrillation. They also utilised prior training and personal networks to enhance their support.

Theme two: impact on patient experiences and clinical outcomes

Communicating in a patient’s Pacific language significantly enhanced their “sense of comfort, trust and engagement” leading to “immediate positive change in demeanour”, including relaxation and expressions of “relief”, “happiness” and “appreciation”. The support also improved patients’ understanding of their medical conditions, health literacy and experiences of medical processes. “When patients understand their care plan, they feel more confident and are more likely to follow through with treatment.”

Nurses described interpreting to assist in emergency medical situations and pre-operative preparations and how this support contributed to improved clinical outcomes. Nurse interpreting roles were a “clinical necessity” for “appropriate care in a timely manner”.

A shared cultural background was essential for rapport, navigating cultural protocols and respectfully addressing sensitive or “tapu” (prohibited or sacred) topics.

Theme three: health system gaps and concerns

Despite positive impacts of their interpreting roles, nurses consistently raised concerns about system gaps in professional interpreter resourcing and availability. They often felt “obligated … to step in at the last minute” due to limited availability of translators, “last minute cancellations [by] interpreting services” or acute patient conditions, despite a lack of formal training or recognition of this role. Nurses advocated for equitable patient care to address language barriers. “I believe that language barriers can adversely impact the person … advocating for them is paramount in my focus to ensure they get a fair deal.”

On the other hand, informal interpreting was time-consuming, interfering with core duties, and raised anxiety about translation accuracy. The absence of institutional support led to a desire for formal medical interpreter training. Significant ethical dilemmas, particularly concerning patient privacy, when interpreting on sensitive topics for individuals they knew personally, were common. “I had to interpret for someone I knew, and it was a sensitive topic.”

Despite these concerns, nurses often felt obligated to assist, particularly if the patient’s condition was acute or in the absence of viable alternative options. This additional work and responsibility to act as interpreters, cultural brokers and patient advocates suggested a significant cultural loading that was uncompensated and absent from job descriptions. “It’s like we’re wearing multiple hats, but no one sees the extra work we’re doing.”

Discussion

This study highlights the essential yet largely informal and unacknowledged role that Pacific nurses play in interpreting for Pacific patients with LEP in Aotearoa New Zealand. Their linguistic capability and deep cultural knowledge enable effective communication, improve patient engagement and enhance clinical outcomes. These contributions are vital to health equity, yet remain structurally unsupported.^19,25 These findings align with prior research during the COVID-19 response, where Pacific nurses were called upon to provide language and cultural support across the health sector, often voluntarily and without recognition.²⁶

A key finding is the scale at which Pacific nurses are called upon to interpret. Among those who spoke a Pacific language, 85% reported being asked to interpret or translate in areas beyond their usual nursing role. These requests came not only from patients and families, but also from colleagues and supervisors, with more than half receiving requests from all three groups. This clearly demonstrates that Pacific nurses are not merely stepping in informally; they are actively and routinely approached to provide language support, revealing both their value and the systemic gaps in professional interpreter provision. Interpreting is not an occasional task for many; it is woven into the fabric of their everyday clinical responsibilities. This reflects broader patterns seen in the health workforce, where Pacific nurses are regularly relied upon to bridge cultural and linguistic gaps without formal support.^26,27

Our findings build on and extend the current literature, which largely focusses on the risks and benefits of using trained versus untrained interpreters.^6,8 While international and national guidelines often frame the use of trained interpreters as best practice,^1,4,28 they rarely consider the culturally nuanced, context-sensitive communication provided by bilingual healthcare staff.^6,16 Pacific nurses in this study described interpreting complex medical concepts using diagrams, metaphors and cultural references that made information more understandable and relatable for patients.^16,22 Their shared cultural background not only improved comprehension but also helped to build rapport, ease patient anxiety and ensure communication aligned with cultural protocols and sensitivities.^6,16 These interactions were more than translation, they were a form of cultural mediation that directly supported patient dignity, safety and engagement.^4,16 The COVID-19 pandemic demonstrated the critical role of culturally grounded communication, with studies showing that the use of Pacific languages improved community understanding and trust, while a lack of such communication contributed to delays in contact tracing and exacerbated health disparities among Pacific populations.^26,29,30

Despite their contributions, Pacific nurses in this study faced ethical and professional challenges in taking on interpreting roles. Many described feeling obligated to say yes, even for highly technical or sensitive procedures, because of last-minute cancellations, a lack of available professional interpreters or an overarching sense of cultural responsibility. These experiences disrupted their primary nursing duties and introduced stress around accuracy, privacy and professional liability, echoing patterns also observed among Māori nurses navigating dual cultural and clinical responsibilities.³¹ For some, the pressure to interpret for individuals they knew personally further complicated ethical boundaries and emotional wellbeing. It has previously been observed that Pacific nurses often internalise stress and avoid labelling their experiences as burnout, instead continuing to meet community needs out of cultural commitment.²⁶

This unrecognised labour is compounded by cultural drivers embedded in Pacific worldviews, such as tautua (service), alofa (love) and tausi (provide care or stewardship).^16,32,33 Unlike Western notions of volunteering, these acts of service are often understood as inherent cultural obligations, not optional extras. Pacific nurses may feel an intrinsic responsibility to help their communities, which the health system can inadvertently exploit.^16,26,32 As other authors have argued, public services may “cynically and knowingly exploit these values and behaviours” and thereby abdicate formal responsibility for resourcing culturally safe care.^29,32 Our study confirms that while Pacific nurses are motivated by cultural values, their contributions are not formally recognised, resourced or protected, creating a moral and operational imbalance. This dynamic has also been noted in workforce responses during public health emergencies, where Pacific nurses were mobilised to serve in high-pressure contexts but later saw their needs and professional contributions deprioritised once the crisis subsided.²⁶

Implications and recommendations

To address the challenges identified in this study, a coordinated set of reforms in policy and practice is urgently needed. First, there is a clear need for the development of targeted training programmes for bilingual nurses. These should focus on Pacific medical terminology, the ethics of interpreting in clinical settings, and guidance on when to refer to professional interpreters, ensuring nurses are equipped to navigate these responsibilities safely and effectively.

In addition, greater investment in professional interpreter services is essential to improve accessibility and reduce the over-reliance on informal interpreting, particularly in under-resourced or high-pressure healthcare environments. It is also important to establish formal recognition and compensation for nurses who regularly provide language and cultural support. This includes defining the scope of these roles, ensuring appropriate workload protections and implementing systems of support and supervision.

Furthermore, policy language and data collection tools should be reviewed and adapted in consultation with Pacific communities.^16,22 Standard terms such as “unpaid work” often fail to capture the cultural significance of contributions embedded in Pacific values like tautua and tausi. Recognising these forms of cultural service within official frameworks would enable more accurate reflection of Pacific nurses’ work and support more culturally responsive policy development.^32,33

Finally, a system-wide commitment is needed to embed culturally informed approaches to workforce planning, resource allocation and care delivery. This will not only lead to improved service outcomes for Pacific patients but also support the wellbeing and professional sustainability of the Pacific health workforce.

Strengths and limitations

This study's key strength lies in its mixed-methods approach, combining quantitative data on prevalence and demographic patterns with rich qualitative insights into nurses’ lived experiences. The high response rate (69%) strengthens the representativeness of the findings, though some response bias may exist, as participants were more likely to be younger, Aotearoa New Zealand–born, and Samoan.

Limitations include the self-reported nature of the data and the constraints of written responses to open-ended questions, which may not have fully captured the complexity of nurses’ experiences. Time constraints, survey format (e.g., mobile devices), or discomfort with written expression may have limited participation. Future studies should consider in-depth interviews or focus groups to build on these findings and explore the emotional, cultural and ethical dimensions of informal interpreting in more detail.

Conclusion

This study reveals a significant gap in Aotearoa New Zealand’s healthcare system: the informal, unpaid and under-recognised interpreting work carried out by Pacific nurses. While their contributions are vital to clinically competent and culturally safe care and patient and family wellbeing, the burden of responsibility has been shifted onto individuals, often without adequate support or acknowledgement. If left unaddressed, this practice risks undermining both patient safety and nurse wellbeing.

Structural solutions, not individual goodwill, must underpin safe and equitable care. This requires a coordinated response: one that recognises and supports Pacific nurses’ dual roles as clinical professionals and cultural intermediaries,³¹ backed by meaningful investment, policy reform and a deeper understanding of the cultural frameworks they bring to healthcare practice. These issues were also observed during the COVID-19 Delta outbreak, when Pacific nurses were central to the health system’s frontline response, yet their professional wellbeing and workforce needs were deprioritised once the immediate crisis passed.²⁶ Addressing this recurring undervaluing of Pacific nurses will require sustained attention beyond times of emergency response.

Finally, the anticipated use of AI-supported interpreting tools in healthcare raises new research questions. These include the need to validate tools for Pacific languages, assess cultural appropriateness and clinical safety and understand how such technologies might alter the ethical responsibilities of nurses asked to use them. These issues should be part of wider implementation research on language access strategies in clinical settings.

View Appendix.