Breaking Down Language Barriers

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Evidence-based approaches to breaking down language barriers

By Allison Squires, PhD, RN, FAAN

LANGUAGE BARRIERS between nurses and patients increas- ingly affect nursing practice, regardless of where care is delivered. In the United States, a language other than English is now spoken at home in one of five households, the high- est level since just after World War I.1 Patients with limited English skills are referred to as patients with limited English proficiency (LEP). This article provides background information about language barriers between nurses and patients and some strategies for ad- dressing these gaps. After detailing how these barriers affect patient outcomes, practice-based strategies are offered to improve outcomes and reduce readmissions. Although the article doesn’t address barriers to communicating with patients with hearing loss, many of the same principles apply to these patients.

Sources of spoken language barriers Globalization means more people move around the world for work and educational opportunities.2 When people migrate, they tend to follow immigrant networks and start recreating communities in their new country.3 People also migrate and 3 become refugees due to wars and civil conflicts. Countries that TOCK accept these refugees place them in communities where they /iS can recover from the trauma of their migration experiences

while seeking work and learning about their new country. PHASINPHOTO

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Structured refugee resettlement has Union, their preferred language How migration dynamics been going on in the United States might be the language of their home affects nurses since after World War II.4 With the country.8 Patients with language barriers exception of Native Americans, just In some parts of the United States, change how nurses work and orga- about everyone in this country is some older immigrants still face a nize care for patients. These changes descended from immigrants. When language barrier. For example, many are needed not only to meet commu- patients have a language barrier, it’s Italians who migrated to the United nication needs for the patient, but often related to when they migrated States in the early 1900s never devel- also for legal reasons. In 1964, the to the United States. oped English language skills and U.S. Civil Rights Act helped ensure • Perhaps unsurprisingly, the largest may still need interpreter services.9 that a lack of English language skills group of migrants in the last 30 years “Language demographics” depends wouldn’t be a source of discrimina- speaks Spanish.5 With only 5% of on who’s moved into your organization.12,13 U.S. law requires that U.S. nurses identifying as Hispanic tion’s service area. healthcare organizations provide or Latino, it’s very common for pa- As people age, some may lose interpreter services to patients with tients in this group to encounter a skills in their second language due LEP.14 New regulations implemented language barrier.6 (No publicly avail- to how the brain changes with ag- as part of the Affordable Care Act able record of language skills of U.S. ing.10 Even those who developed place new restrictions on the use of nurses exists.) strong fluency in English as adults family members and validating lan- • Mandarin and Cantonese Chinese could lose those skills if they have guage skills of health workers.15 speakers are the next largest group.1 significant age-related neurologic Much evidence shows how lan- They’re also underrepresented in events. Some of these older adults guage barriers impact patient out- nursing.7 may end up needing interpreter comes and healthcare delivery. (See • The number of Russian-speaking services. Evidence-based impact of language bar- people in the United States is grow- Another trend involves adults who riers on patient outcomes.) Patients ing quickly. For many Russian- migrated to the United States and with LEP have longer lengths of stay speaking patients, however, Russian then brought their parents over to than English-speaking patients, even is their second or third language. In join the family.11 Although the adult if they have a higher socioeconomic many countries under Soviet rule in children who brought their parents status.16-18 They also have a higher the latter half of the 20th century, to the United States may speak Eng- risk for 30-day readmission, by as people continued to speak their orig- lish well, their parents may not speak much as 25%.18,19 Most of the other inal languages as well as Russian. well enough to communicate effec- outcomes listed in the table are out- With the dissolution of the Soviet tively with a healthcare provider. comes sensitive to nursing practice. How nurses and other healthcare providers respond to the communica- Evidence-based impact of language barriers on tion needs of patients with LEP also patient outcomes has a significant impact on patient satisfaction, with effective use of inter- Outcome preter services or bilingual healthcare Length of stay if interpreter isn’t used at admission or discharge ↑ (3 days) professionals contributing to higher 30-day readmissions (among certain chronic diseases) ↑ risk (15%-25%) patient satisfaction ratings.20-26 Central line-associated bloodstream infections ↑ risk Falls ↑ risk A closer look at medical Surgical site infections ↑ risk interpreters Pressure injuries ↑ risk Aside from facilitating communication between patients and healthcare Surgery delays ↑ risk providers, medical interpreters can ↑ Medication management (for example, adherence, risk also serve as cultural brokers.27-30 understanding discharge instructions) The medical interpreter helps bridge ↓ Preventive screening chance the cultural divide between patients Access to the healthcare system ↓ chance and clinicians. Their translation pro- Source: Betancourt JR, Renfrew MR, Green AR, Lopez L, Wasserman M. Improving patient safety systems for patients with limited English proficiency: a guide for hospitals. Rockville, MD: Agency for Healthcare Research cess ensures that what a nurse says is and Quality; 2012. AHRQ Publication No. 12-0041. https://www.ahrq.gov/sites/default/files/publications/files/ delivered not only with technical lepguide.pdf. accuracy, but also with culturally

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. specific phrasing. Nurses can assess 10 tips for working effectively with an in-person the quality of medical interpreters’ cultural brokerage by observing how medical interpreter the patient responds to the inter- 1. For an in-person interpreter, call the interpreter service and specify the language preter through his or her body needed and about how much time the interpretation will take. language. 2. When the interpreter arrives, introduce yourself and provide a brief report on Medical interpreters have a pro- the work needed and a brief patient history. fessional code of ethics, and they’re 3. Greet the patient and introduce the interpreter. Explain to the patient what will required to comply with it when happen, and let the patient know that he or she can ask the interpreter anything, performing their roles.31 They’re even if it’s not the main reason for the interpretation. Then begin the activity.* bound by the same patient confiden- 4. When working with the interpreter and patient, communicate directly with the tiality requirements as every other patient. Resist the temptation to talk or look at the interpreter, unless you need healthcare team member.31 clarification of something he or she said. Most interpreters hired by health- 5. Speak in shorter sentences than normal. Doing so makes it easier for the inter- care organizations have undergone preter to remember the sentence and improves the translation’s accuracy.* some kind of medical interpreter 6. If the interpreter appears confused about something you’ve said, ask the inter- training because healthcare has its preter if clarification or rephrasing is needed to improve interpretation quality own language.32 According to the for the patient.* National Council on Interpreting in 7. Try not to interrupt the interpreter when he or she is translating the patient’s Health Care, no minimum number of reply. Guessing what the patient is about to say may not always be right, and * course hours is required for inter- some cultures perceive interruptions as very rude behavior. preter training at this time, but it rec- 8. If the interpreter seems to be taking a long time to translate for the patient, it ommends that programs adhere to its may mean that he or she is trying to phrase it in a way that will be best received by the patient. Conversely, if an interpreter simply translates, for exam- curriculum standards, which it devel- ple, “Yes,” to something the patient took a long time to say, that might be an 33 oped in 2011. Implementing a indication of poor translation quality. Make sure the interpreter interprets pa- course that meets the standards usu- tients’ responses completely. Don’t accept a “yes” or “no” when the patient ally requires a minimum of 40 hours gave a lot of information, even when you’re in a hurry. of study and successful live demon- 9. When the encounter finishes, ask the patient if he or she needs anything else stration of the ability to interpret a while the interpreter is there. Many patients have more needs, and often the medical encounter. Participants re- interpreter encounter has made them feel comfortable enough to express them.* ceive a certificate after they’ve com- 10. After leaving the room with the interpreter, review the encounter to ensure pleted a course. They can then take a both interpreter and nurse ended up on the same page. The interpreter may national exam to become a board- also have some cultural insights to share that can help with care planning. 34 certified medical interpreter. Board *These steps also apply to telephone or video interpretation. certification is voluntary at this time. working effectively with an in-person Telephone interpretation can Improving quality of care medical interpreter.) work if implemented well. Accord- and outcomes Some organizations deal with lan- ing to Tuot et al., a good telephone How can nurses help improve patient guage barriers all the time and have interpretation session requires mini- outcomes? These evidence-based excellent resources. They may have an mal waiting time for the phone in- strategies can help nurses better orga- interpreter services department to terpreter, good sound quality so nize their care to improve outcomes. manage the demand for language in- everyone can hear clearly, and an These will also help nurses meet the terpretation services. Some locations outcome in which both patient and Joint Commission requirements for have experience with certain language provider obtain the information bridging language barriers. groups needing translation and need needed.35 • Use the organization’s interpreter interpretation for only a few languag- Nonetheless, both nurses and pa- resources. This isn’t optional. Inter- es. Now, however, many healthcare tients have reported problems with preter resources typically include organizations are seeing more diver- interpretation quality and have ex- in-person interpreters employed by an sity and have a greater need for inter- pressed dislike for the depersonaliza- organization, in-person interpreters preters. Most organizations begin with tion of the patient encounter when contracted through external agencies, interpreter phone services and, if the using the interpreter phone.20,36-39 and telephone- or technology-based demand becomes high enough, begin When no other option is available, interpreter services. (See 10 tips for employing full-time interpreters. however, telephone interpreter www.Nursing2017.com September l Nursing2017 l 37

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. services are best to bridge the lan- Organizations that are imple- guage barrier. New options with live menting AHRQ’s guidelines use video interpretation are also coming name badges that designate the staff onto the market and may replace member’s language skills. Those em- telephone interpreters. ployees have had a formal language Inappropriate interpreter use, skills assessment, understand medi- including nonvalidated translation cal terminology in the languages apps on a nurse’s smart phone, puts they speak, and speak the language the organization at legal risk, as well enough to safely communicate discussed below. Many apps for with patients and families.27 interpretation are available for smart- Every time you ask professional phones, but their accuracy can be staff members to interpret, you take poor and most aren’t compliant with them away from their own patients the Health Insurance Portability and and add to their overall patient case Accountability Act (HIPAA). The load.30,39,42-44 Consider developing an quality of translation they provide is agreement for the patient-care unit so rarely evaluated systematically or nurses with other-than-English lan- using rigorous approaches. Many of guage skills, with their permission, these apps are also designed for can be assigned to language-matching translating only basic sentences, such patients. Even if this means the staff as how to order dinner when travel- member doesn’t have a “geographi- ing. Most computer programs don’t cally efficient” assignment, it will help yet have the sophistication needed to Using a family member to streamline his or her work. translate the language of healthcare. to interpret increases • Document use of medical inter- Use only those apps sanctioned by the risk of medical errors. preter services. Documenting your employer because those have interpreter use is just as important as received a thorough internal review documenting wound care or any other and are HIPAA-compliant. clinical intervention. Document not As a general rule, family mem- resource for interpretation, but this only when an interpreter was used bers, especially children under 18, practice has its own set of risks. but also the type of interpretation. For shouldn’t serve as interpreters, except Use coworkers with other language example, state whether it was at ad- under extenuating circumstances skills appropriately, but only when mission or discharge, or for informed such as an immediate threat to life.40,41 necessary. The Agency for Health- consent or patient teaching. Then Using a family member to interpret care Research and Quality (AHRQ) document whether the interpretation increases the risk that something has developed guidelines for how to was done by a medical interpreter on won’t be translated correctly. For better utilize staff with language staff by telephone, and the interpret- instance, a family member may not skills.27 According to the evidence, er’s name, or with a computer. In feel comfortable conveying some choosing a nurse or other healthcare some cases, depending on the organi- sensitive types of information to the professional who speaks the pa- zation’s policy, the interpreter will be patient, such as about sexual health, tient’s language and who’s had his or required to document the encounter substance abuse, or a terminal diag- her language skills professionally as well. The interpreter will include nosis. Using a family member also evaluated by a language assessment information such as the patient’s increases the risk of medical errors.35 expert is best.32 unique identifier, time and duration Depending on the situation, it may Unlicensed assistive personnel or of the encounter, and any other infor- also violate patient confidentiality housekeeping staff members, who mation required by the organization. protocols. Err on the side of cau- are commonly asked to interpret, When a nurse has to rely on a staff tion and comply with the law: may not have the medical vocabulary member to interpret, either because Don’t use family members for inter- needed to accurately translate for the no human interpreters were available pretation. patient and family. If they become or because of technologic difficulties, • Use care when other staff pro- certified as medical interpreters or documenting the decision making vides interpretation. Staff members the organization assesses their lan- behind that choice will help to who speak the same language as guage skills, however, they can then protect the nurse as well. Showing the patient are another common be used to translate. every effort was made to adhere to

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. organizational policy means the nurse whenever possible, medication in- a survey to investigate intra-hospital variation has done what’s legally required. structions should be in the preferred in attitudes and practices. BMC Health Serv Res. • 2009;9:187. Time interpreter use strategi- language of the patient. Remember 10. Antoniou M, Gunasekera GM, Wong PC. Foreign cally. Research shows that the three that even when someone speaks language training as cognitive therapy for age-related cognitive decline: a hypothesis for future research. critical times when nurses should some English, he or she may not be Neurosci Biobehav Rev. 2013;37(10 Pt 2):2689-2698. use interpreters are at admission, able to read it. An oral review of 11. Acevedo-Garcia D, Bates LM, Osypuk TL, during patient teaching, and at medications using teach-back tech- McArdle N. The effect of immigrant generation and duration on self-rated health among US adults discharge. Using interpreters at niques will help promote adherence, 2003-2007. Soc Sci Med. 2010;71(6):1161-1172. these times decreases the risks of reduce readmissions related to failure 12. The Joint Commission. Language access and medical errors and hospital re- to take new medications or under- the law. Title VI of the U.S. Civil Rights Act (1964). 2008. www.jointcommission.org/assets/1/6/ 18,36,45-47 admissions. stand changes to the old regimen, Lang%20Access%20and%20Law%20Jan%20 How will it help? During admis- and help with care coordination with 2008%20(17).pdf. 27 13. Ku L, Flores G. Pay now or pay later: providing sion, using an interpreter will provide community-based providers. interpreter services in health care. Health Aff more accurate baseline information. (Millwood). 2005;24(2):435-444. That, in turn, will help the healthcare Speaking up 14. Diamond LC, Wilson-Stronks A, Jacobs EA. Do hospitals measure up to the national culturally and team create a more accurate plan of The evidence-based tips for bridging linguistically appropriate services standards? Med care. An interpreter can also help language barriers between nurses and Care. 2010;48(12):1080-1087. nurses tailor patient teaching to the patients with LEP will help nurses 15. Youdelman M. Short Paper #5: The ACA and language access. National Health Law Program. needs of patients and their educa- provide optimal patient care. They can 2011. www.healthlaw.org/issues/health-care- tional level. At discharge, having an apply to nearly every healthcare deliv- reform/aca-and-language-access#.WVaOD4Tyt0w. interpreter present is equally critical, ery setting, with some modification. 16. Karliner LS, Kim SE, Meltzer DO, Auerbach AD. Influence of language barriers on outcomes of even if it delays discharge by a few Remember: Nurses have the re- hospital care for general medicine inpatients. J Hosp hours. 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Int J and family interpreters. Patient Educ Couns. New York, N.Y. She’s also a member of the board of Nurs Stud. 2016;54:158-172. 2008;70(1):87-93. the National Council on Interpreting in Health Care. 33. National Council on Interpreting in Health Care. 42. Bourgeault IL, Atanackovic J, Rashid A, Parpia The author has disclosed that work for this article was National standards for healthcare interpreter training R. Relations between immigrant care workers and funded by the Agency for Healthcare Research and programs. 2011. www.ncihc.org/assets/documents/ older persons in home and long-term care. Can J Quality R01HS023593. The author previously com- publications/National_Standards_5-09-11.pdf. Aging. 2010;29(1):109-118. pleted consulting work for policy analyses with the Migration Policy Institute. The author has disclosed 34. The National Board of Certification for 43. Coomer NM. Returns to bilingualism in the no other financial relationships related to this article. Medical Interpreters. Written exam. www. nursing labor market—demand or ability? J Socio certifiedmedicalinterpreters.org/written-exam. Econ. 2011;40(3):274-284. DOI-10.1097/01.NURSE.0000522002.60278.ca

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