¡Ayúdame! Mi esposo esta inconsciente! No hablo ingles!*

*Help me! My husband is unconscious! I don’t speak English!

Can you imagine what it’s like to live in a country and not be able to speak the language, particularly when healthcare is involved? In the United States, patients with limited English proficiency (LEP) deal with this barrier to healthcare every day in hospitals, clinics, and physician offices. An LEP person is defined as an individual whose primary language isn’t English and who has a limited ability to read, write, speak, and understand English.

What role do language barriers play in healthcare disparities and how can healthcare professionals (HCPs) overcome them? This article describes ways nurse practitioners can prepare to care for patients with LEP.

Can you repeat that?

The American Community Survey Reports conclude that roughly 80 percent of people in the United States over age 5 speak only English at home. The remaining 20 percent speak a language other than English at home, and over 20 percent of this population speak English “not well” or “not at all.” Most of this percentage speaks Spanish (62 percent). These culturally, racially, and lingually diverse people are our patients now, and we may see them more frequently in the future as language variety increases due to recent and future immigration patterns.

I don’t understand

For patients, LEP is a risk factor for healthcare disparities. For healthcare providers, a lack of knowledge about certain cultures and language contributes to these same disparities. LEP can result in multiple problems, including decreased access to preventive health services, dissatisfaction with care, difficulty understanding instructions and/or information about medications and follow-up care, longer hospital stays, and medical errors or misdiagnosis.

These real or potential problems need to be addressed in all settings and healthcare facilities, and even within the 911 operating system. Imagine being a 911 operator who can hear but not understand the foreign words for “help me!”

Speak a little slower

Access to minority language-speaking medical interpreters is one option for improved communication, but they may not be available or affordable, especially in rural areas. In 2000, President Clinton issued an Executive order (#13166) to improve access to services for all persons with LEP regardless of location. This order included federally assisted or conducted agencies, programs, and activities in urban, suburban, and rural areas. Further information about the executive order, resources, and patient rights can be found at a federal interagency website, www.lep.gov.

While LEP services have improved since this executive order, they’re not consistently available. In the absence of minority language-speaking medical interpreters, healthcare providers may try one of the following activities recommended by the Agency for Healthcare Research and Quality.

Simple phrases or instructions can be translated using a translation website when no interpreter assistance is available, but this is time consuming, sometimes inaccurate, and may be difficult or even impossible for some HCPs or patients to do. Using pictures is another option, but having a photo for every situation is impossible.

Patients with some English knowledge who are involved in a teach-back method of learning (for example, metered-dose inhaler use) may be able to understand enough English to write instructions in their native tongue.

Healthcare agencies and providers who receive federal funding are obligated to provide reasonable access to LEP persons. Medical literature is sometimes available in English and Spanish, but not all languages. Some facilities may have employees who fluently speak a non-English language and could assist in translating; however, it should be noted that using staff members or family members as interpreters at healthcare visits should be avoided because privacy and openness could be compromised and the interpreter could insert personal bias into the translation.

There are certain documents that must be translated, according to Health and Human Services guidelines. These documents are vital to patients’ healthcare and include: 

• consent and complaint forms
• documents that must be provided by law
• notices about emergency preparedness and risk communications
• notices of eligibility for benefits
• notices about no-cost language assistance

One more time

When a medical interpreter is used in the clinic, communication is more tedious as questions and information must first be communicated to the interpreter and to the patient, then back to the interpreter, and finally to the HCP. This message cycle is repeated numerous times to gain understanding of the problem and is then repeated again to complete the physical assessment and discuss the treatment plan. This procedure of back and forth with the interpreter in the middle is, however, still very necessary and useful to effectively diagnose and treat the patient.

Improving communication with non-English-speaking patients also occurs when HCPs learn about the language, cultures, values, and beliefs of the patient. Improving the HCPs’ knowledge has the potential to enhance quality care, improve racial and ethnic harmony, and lead to more knowledgeable, culturally competent HCPs. Cultural competency is supported by the Institute of Medicine, which has recommended that cross-cultural education be incorporated into HCPs’ education. Such education may improve distribution of HCPs to areas of need, including rural and underserved locations. Alternately, members of minority communities should be encouraged to become HCPs to help treat all patients, including those from within their own communities.

How nurse practitioners can help

NPs have a critical role in addressing the problems of language-associated healthcare disparities to ensure that access to quality care isn’t influenced by language disparities, socioeconomic status, or other demographic characteristics. What can the nursing professional do when a non-English-speaking patient appears at the door?

First, prepare for this reality as soon as possible by developing a list of questions that can be translated using an interpreter or the Internet. Provide a few options for typical answers, such as colors, sizes, numbers, and so on, in the native tongue with English translations. Make picture boards, focusing on body pictures. Remember that many concepts can be communicated without words. Be sure to use your hands and facial expressions.

Improving outcomes for all patients

Patients who don’t speak English may have limited access to preventive, diagnostic, or therapeutic health services. By meeting the challenge of caring for patients with LEP, nurse practitioners can eliminate or significantly reduce language barriers to optimum healthcare.

REFERENCES

• Limited English Proficiency. Frequently asked questions. http://www.lep.gov/faqs/faqs.html#OneQ1.
• Ryan C. Language use in the United States: 2011. 2013. http://www.census.gov/prod/2013pubs/acs-22.pdf.
• Martin P. U.S. immigration patterns and policies. 2012. http://migrationfiles.ucdavis.edu/uploads/rs/files/2012/ciip/martin-immigration-patterns-policies.pdf.
• Diamond LC, Jacobs EA. Let’s not contribute to disparities: the best methods for teaching clinicians how to overcome language barriers to health care. J GenIntern Med. 2010;25 Suppl 2:S189-S193.
• Padela AI, Punekar IR. Emergency medical practice: advancing cultural competence and reducing health care disparities. Acad Emerg Med. 2009;16(1):69-75.
• Davis JR, Wilson S, Brock-Wilson A, Glover S, Svendsen ER. The impact of disasters on populations with health and healthcare diaparities. Disaster Med Public Health Prep. 2010;4(1):30-38.
• Executive Order 13166. Improving access to services for persons with limited English proficiency. 2000. http://www.justice.gov/crt/lep/13166/eolep.htm.
• McClure DL. Training challenge: when the patient speaks a different language. Adv Perit Dial. 2010;26:88-90.
• Agency for Healthcare Research and Quality. Five key recommendations to improve patient safety for LEP patients. In: Improving Patient Safety Systemsfor Patients with Limited Enlgish Proficiency: A Guide for Hospitals. Rockville, MD:Agency for Healthcare Research and Quality; 2012.
• Department of Health and Human Services. Language access plan. 2013. http://www.hhs.gov/open/execorders/2013-hhs-language-access-plan.pdf.
• Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, D.C.: The National Academies Press; 2003.
• Awosogba T, Belacourt JR, Conyers FG, et al. Prioritizing health disparities in medical education to improve care. Ann N Y. Acad Sci. 2013;1287:17-30.
• Zambrana RE, Carter-Pokras O. Role of acculturation research in advancing science and practice in reducing health care disparities among Latinos. Am J Public Health. 2010;100(1):18-23.
• Danna D. Providing cuturally competent care during disasters: strategies for nurses. J Contin Educ Nurs. 2013;44(4):151-152.

Written by Patricia A. Dettenmeier, DNP, MSN, FNP. This article originally appeared in the June 2014 issue of Nursing © 2014 Lippincott Williams & Wilkins.

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