Language barriers between nurses and patients increasingly 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 highest 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 how these barriers affect patient outcomes. Practice-based strategies are offered to improve outcomes and reduce readmissions. Although this 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 become refugees due to wars and civil conflicts.3 Countries that accept these refugees place them in communities where they can recover from the trauma of their migration experiences while seeking work and learning about their new country. Structured refugee resettlement has been going on in the United States since after World War II.4 With the exception of Native Americans, just about everyone in this country is descended from immigrants. When patients have a language barrier, it's often related to when they migrated to the United States.
The largest group of migrants in the last 30 years speaks Spanish.5 With only 5% of U.S. nurses identifying as Hispanic or Latino, it's very common for patients in this group to encounter a language barrier.6 (No publicly available record of language skills of U.S. nurses exists.) Mandarin and Cantonese Chinese speakers are the next largest group.1 They're also underrepresented in nursing.7 The number of Russian-speaking people in the United States is growing quickly. However, for many Russian-speaking patients, Russian is their second or third language. In many countries under Soviet rule in the latter half of the 20th century, people continued to speak their original languages as well as Russian. With the dissolution of the Soviet Union, their preferred language may be the language of their home country.8
In some parts of the United States, some older immigrants still face a language barrier. For example, many Italians who migrated to the United States in the early 1900s never developed English language skills and may still need interpreter services.9 Language demographics depend on who's moved into your organization's service area. As people age, some may lose skills in their second language due to how the brain changes with aging.10 Even those who developed strong fluency in English as adults can lose those skills if they have significant age-related neurologic events. Some of these older adults may end up needing interpreter services.
Another trend involves adults who migrated to the United States and then brought their parents over to join the family.11 Although the adult children who brought their parents to the United States may speak English well, their parents may not speak English well enough to communicate effectively with a healthcare provider.
How migration dynamics affect nurses
Patients with language barriers change how nurses work and organize patient care. These changes are needed not only to meet communication needs for the patient, but also for legal reasons. In 1964, the U.S. Civil Rights Act helped ensure that a lack of English language skills wouldn't be a source of discrimination.12,13 U.S. law requires that healthcare organizations provide interpreter services to patients with LEP.14 Regulations implemented as part of the Affordable Care Act place new restrictions on the use of family members and validating language skills of healthcare workers.15
Much evidence shows how language barriers impact patient outcomes and healthcare delivery. (See Table 1.) Patients with LEP have longer lengths of stay than English-speaking patients, even if they have a higher socioeconomic status.16-18 They also have a higher risk of 30-day readmission, by as much as 25%.18,19
How nurses and other healthcare providers respond to the communication needs of patients with LEP also has a significant impact on patient satisfaction, with effective use of interpreter services or bilingual healthcare professionals contributing to higher patient satisfaction ratings.20-26
A closer look at medical interpreters
Aside from facilitating communication between patients and healthcare providers, medical interpreters can also serve as cultural brokers.27-30 The medical interpreter helps bridge the cultural divide between patients and clinicians. The translation process ensures that what a nurse says is delivered not only with technical accuracy, but also with culturally specific phrasing. Nurses can assess the quality of medical interpreters' cultural brokerage by observing how the patient responds to the interpreter through his or her body language.
Medical interpreters have a professional code of ethics that binds them to the same patient confidentiality requirements as every other healthcare team member.31 Most interpreters hired by healthcare organizations have undergone some kind of medical interpreter training because healthcare has its own language.32 According to the National Council on Interpreting in Health Care, no minimum number of course hours is required for interpreter training at this time, but it recommends that programs adhere to its curriculum standards, which were developed in 2011.33 Implementing a course that meets the standards usually requires a minimum of 40 hours of study and successful live demonstration of the ability to interpret a medical encounter. Participants receive a certificate after they've completed the course. They can then take a national exam to become a board-certified medical interpreter.34 Board certification is voluntary at this time.
Improving care quality and outcomes
How can nurses help improve outcomes for patients with LEP? These evidence-based strategies can help nurses better organize their care to improve outcomes and meet The Joint Commission requirements for bridging language barriers.
Use the organization's interpreter resources. Interpreter resources typically include in-person interpreters employed by an organization, in-person interpreters contracted through external agencies, and telephone- or technology-based interpreter services. (See Table 2.)
Some organizations deal with language barriers all of the time and have excellent resources. They may have an interpreter services department to manage the demand for language interpretation services. Some locations have experience with certain language groups and need interpretation for only a few languages. However, many healthcare organizations are seeing more diversity and have a greater need for interpreters. Most organizations begin with interpreter phone services and, if the demand becomes high enough, hire full-time interpreters.
Telephone interpretation can work if implemented well. A good telephone interpretation session requires minimal waiting time for the phone interpreter, adequate sound quality so that everyone can hear clearly, and an outcome in which both the patient and provider obtain the information needed.35
Nonetheless, both nurses and patients have reported problems with interpretation quality, expressing dislike for the depersonalization of the patient encounter when using the interpreter phone.20,36-39 However, when no other option is available, telephone interpreter services are the best way to bridge the language barrier. New options with live video interpretation are also coming onto the market and may replace telephone interpreters.
Inappropriate interpreter use, including nonvalidated translation apps on a nurse's smartphone, puts the organization at legal risk. Many apps for interpretation are available for smartphones, but their accuracy can be poor and most aren't compliant with the Health Insurance Portability and Accountability Act (HIPAA). The quality of translation is rarely evaluated systematically or using rigorous approaches. Many of these apps are also designed for translating only basic sentences, such as how to order dinner when traveling. Most computer programs don't yet have the sophistication needed to translate the language of healthcare. Use only those apps sanctioned by your employer that have undergone a thorough internal review and are HIPAA-compliant.
As a general rule, family members, especially children younger than age 18, shouldn't serve as interpreters, except under extenuating circumstances such as an immediate threat to life.40,41 Using a family member to interpret increases the risk that something won't be translated correctly. For instance, a family member may not feel comfortable conveying some sensitive types of information to the patient, such as about sexual health, substance abuse, or a terminal diagnosis. Using a family member also increases the risk of medical errors.35 Depending on the situation, it may also violate patient confidentiality protocols. Err on the side of caution: Don't use family members for interpretation.
Get your professional staff members who speak other languages fluently certified for their skills and help them obtain medical interpreter training. It's inevitable that staff members who speak other languages will get pulled in to interpret at the last minute or when an interpreter isn't available. Help reduce the risk of adverse outcomes related to poor quality translation by getting your staff certified and trained.
Use care when other staff members provide interpretation. Staff members who speak the same language as the patient are a common resource for interpretation, but this practice has its own set of risks. Use coworkers with language skills appropriately, but only when necessary. The Agency for Healthcare Research and Quality (AHRQ) has developed guidelines for how to better utilize staff members with language skills.27 According to the evidence, choosing a nurse or other healthcare professional who speaks the patient's language and who's had his or her language skills professionally evaluated by a language assessment expert is best.32
Unlicensed assistive personnel or housekeeping staff members, who are commonly asked to interpret, may not have the medical vocabulary needed to accurately translate for the patient and family. If they become certified as medical interpreters or the organization assesses their language skills, however, they can then be used to translate.
Organizations that are implementing the AHRQ guidelines use name badges that designate the staff member's language skills. Those employees have had a formal language skills assessment, understand medical terminology in the languages they speak, and speak the language well enough to safely communicate with patients and families.27
Every time you ask professional staff members to interpret, you take them away from their own patients and add to their overall patient case load.30,39,42,43 Consider developing an agreement for the patient care unit so that nurses with other-than-English language skills, with their permission, can be assigned to language-matching patients. Even if this means the staff member doesn't have a “geographically efficient” assignment, it will help to streamline his or her work.
Document the use of medical interpreter services. Documenting interpreter use is just as important as documenting wound care or any other clinical intervention. Document not only when an interpreter was used, but also the type of interpretation. For example, state whether it was at admission or discharge, or for informed consent or patient teaching. Then document whether the interpretation was done by a medical interpreter on staff by telephone or with a computer, and the interpreter's name. In some cases, depending on the organization's policy, the interpreter will be required to document the encounter as well. The interpreter will include information such as the patient's unique identifier, time and duration of the encounter, and any other information required by the organization.
When a nurse has to rely on a staff member to interpret, either because no interpreters were available or because of technologic difficulties, documenting the decision making behind that choice will also help protect the nurse. Showing that every effort was made to adhere to organizational policy means the nurse has done what's legally required.
Time interpreter use strategically. Research shows that the three critical times when nurses should use interpreters are at admission, during patient teaching, and at discharge. Using interpreters at these times decreases the risks of medical errors and hospital readmissions.18,36,44-46
How will it help? During admission, using an interpreter will provide more accurate baseline information. That, in turn, will help the healthcare team create a more accurate care plan. An interpreter can also help nurses tailor patient teaching to the needs of patients and their educational level. At discharge, having an interpreter present is equally critical, even if it delays discharge by a few hours. A good patient discharge process with an interpreter will decrease the risk that patients will be readmitted because they didn't understand how to take their medications or other discharge instructions.18,46
An idea for a clinical ladder project is to have discharge instructions and patient education materials translated into languages spoken by many patients. Bilingual discharge instructions also ensure that when patients are referred for home health services, home healthcare nurses who don't speak their language can also read the discharge instructions. The more resources that can be used for teaching and facilitating discharge for patients with LEP, the less likely they are to be readmitted or visit the ED.18,46
Prioritize patient understanding of medication management. Medication adherence is complex when patients speak English, but even more so when patients have LEP.47,48 First, medications may have different names in other countries, even in other English-speaking countries, and may require translation. Second, whenever possible, medication instructions should be in the patient's preferred language. Remember that even when someone speaks some English, he or she may not be able to read it. A review of medications using teach-back techniques helps promote adherence, reduce readmissions related to failure to take new medications or understand changes to the old regimen, and help with care coordination with community-based providers.27
Prioritize hiring professional staff members who speak the languages of your patients. If you have professional staff members who speak the language of your LEP patients, you have an excellent chance of improving patient outcomes and satisfaction. You can determine the demand for these nurses by looking at the census of your non-English-speaking patient population. It's also worth paying them at a higher hourly rate because their language skills will reduce interpreter costs, improve outcomes, and reduce the risk of costly adverse events.43
These evidence-based tips for bridging language barriers between nurses and patients with LEP help nurses provide optimal patient care. They can apply to nearly every healthcare delivery setting, with some modification. Remember: Nurses have the responsibility to do their best to bridge language barriers with their patients to adhere to practice standards and improve patient outcomes.
INSTRUCTIONS Strategies for overcoming language barriers in healthcare
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1. Ryan C. Language use in the United States: 2011. www.census.gov/prod/2013pubs/acs-22.pdf
2. Shaffer FA, Davis CR, To Dutka J, Richardson DR. The future of nursing: domestic agenda, global implications. J Transcult Nurs
3. Czaika M, de Haas H. The globalization of migration: has the world really become more migratory? http://onlinelibrary.wiley.com/doi/10.1111/imre.12095/full
4. Miner SM, Liebel D, Wilde MH, Carroll JK, Zicari E, Chalupa S. Meeting the needs of older adult refugee populations with home health services. J Transcult Nurs
5. U.S. Census. Facts for features: Hispanic Heritage Month 2015. www.census.gov/newsroom/facts-for-features/2015/cb15-ff18.html
6. U.S. Health Resources and Services Administration. The future of the nursing workforce: national- and state-level projections, 2012-2025. https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/nursingprojections.pdf
7. U.S. Health Resources and Services Administration. Sex, race, and ethnic diversity of U.S. health occupations (2011-2015). https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/diversityushealthoccupations.pdf
8. Shpilko I. Russian-American health care: bridging the communication gap between physicians and patients. Patient Educ Couns
9. Hudelson P, Vilpert S. Overcoming language barriers with foreign-language speaking patients: a survey to investigate intra-hospital variation in attitudes and practices. BMC Health Serv Res
10. Antoniou M, Gunasekera GM, Wong PC. Foreign language training as cognitive therapy for age-related cognitive decline: a hypothesis for future research. Neurosci Biobehav Rev
. 2013;37(10 Pt 2):2689–2698.
11. Acevedo-Garcia D, Bates LM, Osypuk TL, McArdle N. The effect of immigrant generation and duration on self-rated health among US adults 2003-2007. Soc Sci Med
12. The Joint Commission. Language access and the law. Title VI of the U.S. Civil Rights Act (1964). www.jointcommission.org/assets/1/6/Lang%20Access%20and%20Law%20Jan%202008%20(17).pdf
13. Ku L, Flores G. Pay now or pay later: providing interpreter services in health care. Health Aff (Millwood)
14. Diamond LC, Wilson-Stronks A, Jacobs EA. Do hospitals measure up to the national culturally and linguistically appropriate services standards. Med Care
16. Karliner LS, Kim SE, Meltzer DO, Auerbach AD. Influence of language barriers on outcomes of hospital care for general medicine inpatients. J Hosp Med
17. Levas MN, Cowden JD, Dowd MD. Effects of the limited English proficiency of parents on hospital length of stay and home health care referral for their home health care-eligible children with infections. Arch Pediatr Adolesc Med
18. Lindholm M, Hargraves JL, Ferguson WJ, Reed G. Professional language interpretation and inpatient length of stay and readmission rates. J Gen Intern Med
19. Prescott HC, Langa KM, Iwashyna TJ. Readmission diagnoses after hospitalization for severe sepsis and other acute medical conditions. JAMA
20. Bagchi AD, Dale S, Verbitsky-Savitz N, Andrecheck S, Zavotsky K, Eisenstein R. Examining effectiveness of medical interpreters in emergency departments for Spanish-speaking patients with limited English proficiency: results of a randomized controlled trial. Ann Emerg Med
21. Diamond LC, Tuot DS, Karliner LS. The use of Spanish language skills by physicians and nurses: policy implications for teaching and testing. J Gen Intern Med
22. Fatahi N, Mattsson B, Lundgren SM, Hellström M. Nurse radiographers' experiences of communication with patients who do not speak the native language. J Adv Nurs
23. Nápoles AM, Gregorich SE, Santoyo-Olsson J, O'Brien H, Stewart AL. Interpersonal processes of care and patient satisfaction: do associations differ by race, ethnicity, and language. Health Serv Res
24. Radwin LE, Cabral HJ, Woodworth TS. Effects of race and language on patient-centered cancer nursing care and patient outcomes. J Health Care Poor Underserved
25. Taylor RA, Alfred MV. Nurses' perceptions of the organizational supports needed for the delivery of culturally competent care. West J Nurs Res
26. Whitman MV, Davis JA, Terry AJ. Perceptions of school nurses on the challenges of service provision to ESL students. J Community Health
27. 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 and Quality; 2012.
28. Dohan D, Levintova M. Barriers beyond words: cancer, culture, and translation in a community of Russian speakers. J Gen Intern Med
. 2007;22(suppl 2):300–305.
29. Hilfinger Messias DK, McDowell L, Estrada RD. Language interpreting as social justice work: perspectives of formal and informal healthcare interpreters. ANS Adv Nurs Sci
30. Lo MC. Cultural brokerage: creating linkages between voices of lifeworld and medicine in cross-cultural clinical settings. Health (London)
31. National Council on Interpreting in Health Care. National Council on Interpreting in Health Care develops national standards for interpreters. www.ncihc.org/ethics-and-standards-of-practice
32. Hull M. Medical language proficiency: a discussion of interprofessional language competencies and potential for patient risk. Int J Nurs Stud
33. National Council on Interpreting in Health Care. National standards for healthcare interpreter training programs. www.ncihc.org/assets/documents/publications/National_Standards_5-09-11.pdf
34. The National Board of Certification for Medical Interpreters. Written exam. www.certifiedmedicalinterpreters.org/written-exam
35. Tuot DS, Lopez M, Miller C, Karliner LS. Impact of an easy-access telephonic interpreter program in the acute care setting: an evaluation of a quality improvement intervention. Jt Comm J Qual Patient Saf
36. Gany F, Kapelusznik L, Prakash K, et al. The impact of medical interpretation method on time and errors. J Gen Intern Med
. 2007;22(suppl 2):319–323.
37. Gany F, Leng J, Shapiro E, et al. Patient satisfaction with different interpreting methods: a randomized controlled trial. J Gen Intern Med
. 2007;22(suppl 2):312–318.
38. Grover A, Deakyne S, Bajaj L, Roosevelt GE. Comparison of throughput times for limited English proficiency patient visits in the emergency department between different interpreter modalities. J Immigr Minor Health
39. McDowell L, Hilfinger Messias DK, Estrada RD. The work of language interpretation in health care: complex, challenging, exhausting, and often invisible. J Transcult Nurs
40. Brisset C, Leanza Y, Laforest K. Working with interpreters in health care: a systematic review and meta-ethnography of qualitative studies. Patient Educ Couns
41. Rosenberg E, Seller R, Leanza Y. Through interpreters' eyes: comparing roles of professional and family interpreters. Patient Educ Couns
42. Bourgeault IL, Atanackovic J, Rashid A, Parpia R. Relations between immigrant care workers and older persons in home and long-term care. Can J Aging
43. Coomer NM. Returns to bilingualism in the nursing labor market—demand or ability. J Socio Econ
44. Dowsey MM, Broadhead ML, Stoney JD, Choong PF. Outcomes of total knee arthroplasty in English- versus non-English-speaking patients. J Orthop Surg (Hong Kong)
45. Jackson C, Shahsahebi M, Wedlake T, DuBard CA. Timeliness of outpatient follow-up: an evidence-based approach for planning after hospital discharge. Ann Fam Med
46. Leanza Y, Boivin I, Rosenberg E. Interruptions and resistance: a comparison of medical consultations with family and trained interpreters. Soc Sci Med
47. Moreno G, Lin EH, Chang E, et al. Disparities in the use of internet and telephone medication refills among linguistically diverse patients. J Gen Intern Med
48. Regenstein M, Andres E, Nelson D, David S, Lopert R, Katz R. Medication information for patients with limited English proficiency: lessons from the European Union. J Law Med Ethics