COMMUNICATION BETWEEN healthcare staff and patients is a key component of diagnosis and treatment.1 In 2013, about 41% of the U.S. population, an estimated 25.1 million people, had limited English proficiency (LEP).2 Many healthcare clinicians don't use the interpretation services available and underutilize the professional interpretation staff.3 According to the Patient Protection and Affordable Care Act (ACA) in 2016, an individual is qualified to interpret if he or she maintains client confidentiality and ethical principles, has proficiency in the language needed for interpretation, and can accurately vocalize the information being interpreted using correct terminology, such as medical terms.4 (See What does the law say?) This article discusses how an acute care hospital improved interpretation services on a medical-surgical unit.
Many areas are becoming more culturally diverse, making providing culturally competent care more important and, at times, more challenging. Language barriers are often an obstacle to providing culturally competent care.3
Patients feel more comfortable and trust healthcare staff more when a qualified medical interpreter is present. When no such interpreter is present, patients feel that healthcare staff “didn't tell me much” and believe they aren't receiving all the important information they need.5 Not having a qualified medical interpreter present can also lead to critical miscommunications affecting patient care.6,7
Many times, healthcare staff members aren't sure when using a qualified medical interpreter instead of an untrained interpreter (such as a friend, family member, or untrained bilingual hospital staff) is necessary.7 In a study by Hadziabdic and colleagues, only 53% of patients feel that they can confidently use a family member as an accurate translator.8 Half of the questions interpreted by untrained interpreters are translated incorrectly.9 When healthcare workers have used untrained interpreters, staff members may feel that the person interpreting is withholding information from the patient or has a personal agenda while interpreting.7,9 This shows that healthcare staff can't always confidently use family members to accurately translate information, and patients may not be comfortable using their own family as interpreters. Using a nonqualified person to interpret information in a nonemergent situation is against the requirements of interpretation per the ACA as previously mentioned.4
Although using face-to-face qualified medical interpreters may be the preferred method of communication, finances and time management don't always allow this to take place.10 For this reason, guidelines are needed to educate staff about when to use qualified medical interpreters and when it may be appropriate to use an untrained interpreter for daily activities such as bathing.
Assessing the issue
The previous practice on the medical-surgical unit at a local acute care hospital included a policy that wasn't specific to nursing and was difficult to locate within the organization's policies and procedures. The policy provided general guidelines about when to use a qualified medical interpreter and what should be documented in the patient's medical record about the qualified medical interpreter's use. Because some staff members weren't aware of the policy and others had never reviewed the policy, it wasn't consistently being followed throughout the hospital. For example, a “waiver of interpreter services” form must be completed if the patient refuses to use a qualified medical interpreter or the language interpretation phone line. Many staff members weren't aware of the waiver form.11
To better care for patients with LEP, an evidence-based practice guide was created to help nursing staff determine when interpreters are needed and, specifically, when an experienced medical interpreter must be used without exception.
A literature search was conducted to find best practices for language interpretation. Articles were compared to better understand the proper use of qualified medical interpreters versus untrained interpreters or patients' family members. The literature was also reviewed to determine when the medical interpreters should be used, such as during patient admission to the hospital and for the nurse's initial physical assessment.
The databases EBSCOhost, Ovid, and CINAHL were used to conduct the search. Keywords included language∗, barrier∗, interp∗, nurs∗, and communicat∗. The search was limited to peer-reviewed articles published within the last 6 years.
Communication between healthcare staff and patients in the patient's preferred language is necessary to deliver the appropriate diagnosis, education, and treatment in the hospital. If a patient doesn't clearly understand what the healthcare provider or nurse is explaining, the patient may misinterpret the healthcare provider's findings and diagnosis. The same goes for the clinician who misunderstands the patient's complaints or report of symptoms due to underusing interpretation services.1
Many of the articles reviewed mentioned the phrase “getting by” to describe the misuse of interpretation services or the use of untrained interpreters to communicate with patients and their families.1,3 Juckett and Unger noted that Americans who speak English “less than very well” were less likely to receive proper preventive care, including access to regular checkups or healthcare.7
These patients also have a decreased satisfaction rate for the care provided to them. The risk of decreased satisfaction rates is partially based on underutilized qualified interpreter services as well as on medical errors and unnecessary procedures caused by using family, friends, or untrained interpreters as the main form of communication between healthcare providers and patients.6 Misunderstood signs and symptoms can lead to missed or incorrect diagnoses and malpractice exposure.7
Several interpretation services are available, including professional medical interpreters, telephone interpreters, or videoconference interpreters. Bilingual staff or family members who speak English should be used for interpretation only for activities such as bathing or dressing or if the patient refuses a qualified interpreter.3
The best choice of interpretation service is based on the specific situation. A general medical practice in New Zealand developed a toolkit to determine patients' interpretation needs by assessing their English language ability and the context of the situation in the healthcare setting.6 The toolkit helped clinicians determine the patient's preferred language and level of English proficiency, then concluded whether the patient would need a qualified medical interpreter or could use untrained bilingual family or staff for interpretation. The flowchart created for nursing staff at the local acute care hospital was based on the New Zealand toolkit to help nurses choose the best interpretation service for communicating with a patient with LEP.6
The flowchart developed for the nursing staff on a medical-surgical unit at the local acute care hospital reviews various situations a patient experiences as an inpatient. (See Flowchart for language interpretation.) The first step in the flowchart reviews the patient's and family's English language proficiency and the importance of discussing the interpretation services available for communication. A plan of care is also initiated in the patient's medical record.
If the family needs interpretation services, the nurse should proceed to the next step on the flowchart, which includes use of the interpretation toolbox and notice of services form. The toolbox includes a telephone used for language interpretation, which is placed directly in the patient's room. A “Notice of services” handout informs the patient and family of the services available at the hospital. This form is in our acute care facility's organizational administration policy about communication with non-English-speaking patients.
A patient can refuse interpretation services, but a waiver of interpreter services form needs to be signed by the patient and documented in the patient's medical record. The other steps on the flowchart can be followed after the nurse has discussed available interpretation services with the patient, using a medical interpreter, and has obtained equipment needed for interpretation, such as the telephone used for the language line. The patient may refuse further use of either service, but it will be necessary to initially discuss how the patient wants to communicate with healthcare staff.
The aspects of care requiring interpretation services were chosen based on the importance of the information being communicated and with whom the patient is speaking. If the patient and nurse are performing basic nursing care, such as bathing or dressing, the family or bilingual untrained staff fluent in the patient's preferred language could be used for interpretation. If the nurse or healthcare provider is performing assessments, the telephone language line is preferred so the clinician knows the correct information is being communicated with the patient.7
During admission, discharge, or other important education, such as after a new diabetes diagnosis, the telephone language interpretation or qualified medical interpreter must be used. This ensures the patient understands the information being communicated. Using untrained interpreters who may be unfamiliar with medical terms could lead to a longer length of stay or possible readmission if the patient misunderstands instructions. In addition, using untrained interpreters could lead to a breach in privacy, embarrassment, or be against the law if the information discussed is confidential or considered an intimate subject by the patient.4,7
The last step states the language services should be used during healthcare provider bedside rounding and when obtaining consent for a procedure such as surgery. Making the most of the interpretation services improves clinical care, increases patient satisfaction, and is associated with a shorter hospital stay and a lower risk of readmission.7
While caring for patients who need an interpreter, the nurse should follow certain techniques and processes. For example, always speak directly to patients when communicating rather than to the interpreter. This indicates to patients that the provider is listening and responding directly to questions or concerns about patient care.7 Allowing extra time during assessments or patient interviews gives the nurse the opportunity to discuss necessary information, such as disease process and signs and symptoms or education materials, with an interpreter present.7
Encourage other members of the patient's healthcare team, especially healthcare providers such as physicians, to use the interpretation services when interviewing or assessing the patient. The healthcare provider must use either a telephone interpretation service or a face-to-face medical interpreter to communicate with the patient. The nurse can schedule a time for both the interpreter and healthcare provider to be at the bedside for the benefit of the patient during bedside rounding, which can increase patient safety and understanding.1
Nurses need to be educated about how to call for the interpretation services and how to use the language telephone. The language flowchart guides nurses through proper use of language interpretation services.
Documentation of the interpretation services used should include the name of the interpreter in a basic nursing progress note. If the patient refuses the interpretation services or prefers a family member to interpret instead of using a qualified medical interpreter for personal reasons, the refusal should also be documented in a progress note. A qualified interpreter should continue to be offered or provided for interpretation services by the healthcare staff even if a patient completes the waiver of interpreter services form.4
Advocate for better communication
Overall, the use of interpretation services improves patient satisfaction and understanding.3 Nurses play an important role in advocating for patients with LEP and setting up the equipment needed for communication. The availability and use of interpretation services in the hospital setting significantly increases the quality and safety of patient care.1
What does the law say?
In 1964, the U.S. Civil Rights Act helped ensure that a lack of English language skills wouldn't be a source of discrimination.13,14 A subsection of the ACA, revised in 2016, requires providers to offer a qualified interpreter to patients with LEP.
In the past, Department of Health and Human Services regulations merely required that oral interpreters be “competent” and “formal certification was not required.” Under the new rule, a “qualified interpreter” is defined as an interpreter who “via a remote interpreting service or an on-site appearance” 1) adheres to generally accepted interpreter ethics principles, including client confidentiality; 2) has demonstrated proficiency in speaking and understanding both spoken English and at least one other spoken language; and 3) is able to interpret effectively, accurately, and impartially, both receptively and expressly, to and from such language(s) and English, using any necessary specialized vocabulary and phraseology.”4
1. López L, Rodriguez F, Huerta D, Soukup J, Hicks L. Use of interpreters by physicians for hospitalized limited English proficient patients and its impact on patient outcomes. J Gen Intern Med
2. Zong J, Batalova J. The limited English proficient population in the United States. Migration Policy Institute. 2015. www.migrationpolicy.org/article/limited-english-proficient-population-united-states
3. Hsieh E. Not just “getting by”: factors influencing providers' choice of interpreters. J Gen Intern Med
4. Hunt D. New 2016 ACA rules significantly affect the law of language access. 2016. www.cmelearning.com/new-2016-aca-rules-significantly-affect-the-law-of-language-access
5. Fryer CE, Mackintosh SF, Stanley MJ, Crichton J. ‘I understand all the major things’: how older people with limited English proficiency decide their need for a professional interpreter during health care after stroke. Ethn Health
6. Gray B, Hilder J, Stubbe M. How to use interpreters in general practice: the development of a New Zealand toolkit. J Prim Health Care
7. Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician
8. Hadziabdic E, Albin B, Hjelm K. Arabic-speaking migrants' attitudes, opinions, preferences and past experiences concerning the use of interpreters in healthcare: a postal cross-sectional survey. BMC Res Notes
9. McCarthy J, Cassidy I, Graham MM, Tuohy D. Conversations through barriers of language and interpretation. Br J Nurs
10. Hart PL, Mareno N. Cultural challenges and barriers through the voices of nurses. J Clin Nurs
11. WellSpan Health York Hospital Policy. Effective communication and services for people who are deaf and hearing impaired or non-English speaking. Wellspan Manual of Administrative Policy
. 2014. Wellspan INET Policies.
12. U.S. Department of Justice. Improving access to services for persons with limited English proficiency. Title VI of the Civil Rights Act of 1964; Executive Order 13166
. 2015. www.justice.gov/crt/executive-order-13166
13. The Joint Commission. Language access and the law. Title VI of the U.S. Civil Rights Act (1964). 2008. www.jointcommission.org/assets/1/6/Lang
Access and Law Jan 2008 (17).pdf.
14. Ku L, Flores G. Pay now or pay later: providing interpreter services in health care. Health Aff (Millwood)
15. Diamond LC, Wilson-Stronks A, Jacobs EA. Do hospitals measure up to the national culturally and linguistically appropriate services standards. Med Care