DIVERSITY IN HEALTHCARE: SPANISH-SPEAKING PATIENTS WITH LIMITED ENGLISH PROFICIENCY

JENNIFER McANALLY, DNP, PMHNP-BC

Jennifer McAnally holds a Doctor of Nursing Practice degree and specializes in the field of family psychiatry. She has worked in child and adult mental health and substance use treatment settings for over 10 years. She is currently an assistant professor of nursing and instructs both undergraduate and graduate nursing students. She worked previously in academic research settings and as the medical device division manager of a biomedical firm and tissue bank. She has also worked in regulatory oversight of Medicaid programs at the state level. Jennifer’s earlier degrees include a Bachelor of Science in Nursing and Bachelor of Science in Microbiology with emphasis on whole-genome bioinformatics, both from Montana State University. Jennifer is a passionate activist in the field of mental health services, and is dedicated as a mother of two children, to family and to her community in Montana.

Abstract

For many non-English speaking persons the national goal of access to quality healthcare is unachieved and health disparities prevail. A large number of these individuals speak Spanish as a primary language, and the Hispanic or Latino population is the largest minority group in the United States. Communicating with patients and families in their native language as much as is possible in the healthcare setting is important. Many healthcare organizations have resources for non-English speaking patients and families, including use of a telephone interpretation service, mobile phone online app, or by having a medical interpreter available. The use of a medical interpreter is ideal although not all organizations have them available at all times. Family members are a helpful resource for individuals that need an interpreter to understand a medical procedure or condition.

2 NurseCe4Less.com

Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. Continuing Education Credit Designation This educational activity is credited for 2 hours at completion of the activity. Statement of Learning Need As the Hispanic population continues to grow in the U.S. so does the need for healthcare workers who speak Spanish. Organizations such as the NAHN (National Association of Hispanic Nurses) identify the need for more nursing participation at all levels to improve the quality of health care in Hispanic communities and, hence, reduce the health disparity among its members

Course Purpose This course will increase learners’ knowledge and skills related to Medical Spanish and common words that can be used when individuals require an interpreter. Target Audience Advanced Practice Registered Nurses, Registered Nurses, and other Interdisciplinary Health Team Members.

Disclosures Jennifer McAnally, DNP, PMHNP-BC, William Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, PMHNP-BC, MSN, MA – all have no disclosures. There is no commercial support.

3 NurseCe4Less.com

Self-Assessment of Knowledge Pre-Test: 1. Health equity means that all people, regardless of ethnicity, race

or status,

a. will have a positive outcome to any health issue. b. can attain the highest level of health. c. will have a healthcare provider who speaks their language. d. receive the same healthcare services and treatments.

2. The terms “Hispanic” and “Latino”

a. are not the same. b. mean the same thing. c. refer to individuals from Spain. d. refers to people from Spain and Rome respectively.

3. The Latino population is expected to make up ______ of the total

population of the United States by the year 2060.

a. one-tenth b. one-third c. 26.5% d. 50%

4. The effects of limited English proficiency (LEP) on healthcare

services can impact

a. the admissions process. b. patient discharge. c. end-of-life decision making. d. All of the above

5. True or False: Disparities in healthcare do not occur with LEP

persons who are comfortable speaking English.

a. True b. False

4 NurseCe4Less.com

Introduction

Population statistics in the United States indicate that the number of Spanish-speaking individuals in this country are growing. Many of these individuals are not proficient in English. In the United States, English language and communication skills factor into whether a patient will experience positive outcomes when receiving healthcare services, beginning with access to care, treatment, adherence, and followup. Language barriers for Hispanics who are not proficient in English are partly responsible for disparities in the healthcare services, leading to inequities in health for Hispanic populations. Taking reasonable steps to remove barriers is required under federal law when federal aid is involved, as well as under the laws of some states. Adequate language skills of healthcare personnel or language interpretation or translation technologies are possible ways health equity can be attained across all patient populations.

Growth of Spanish-speaking U.S. Populations

Speaking English increases a person’s ability to identify and access healthcare services in most parts of the United States. This means that for non-English speaking individuals, access to quality healthcare is difficult. The magnitude of this problem is considerable since around 20% of adults living in the U.S., reside in a non-English-speaking household.1 Nearly half of people living in a non-English-speaking household may be categorized as having limited English proficiency (LEP).1 According to the U.S. Census Bureau, 8.3% of the American population do not speak English well and should be considered LEP persons for healthcare purposes.2

Although often used interchangeably, the terms “Hispanic” and “Latino” are not the same. Caballero, et al. (2011) described that Hispanic refers to “people born in a country conquered by Spaniards and for whom Spanish is the primary language.”3 The term Latino refers to people born in a country whose language evolved from Latin or the Romance languages.3

5 NurseCe4Less.com

The Hispanic population in the United States has increased significantly over the past decades and is expected to continue to increase within all geographic regions of the United States. Noe-Bustamante, et al. (2020) reported that the U.S., Latino population hit a record 60.6 million in 2019. Moreover, Latinos accounted for 52% of the total U.S. population growth from 2010 through 2019.4 The Latino population grew nationwide with the greatest growth happening in the South.4 Noe-Bustamante, et al. added that while Latino populations had increased across the U.S., it was also slowing.4 Nevertheless, they stated that “Latinos remain an important part of the nation’s overall demographic story.”4 In fact, the Latino population is expected to reach 111.2 million (26.5% of the total U.S., population) by 2060.5

The growth of Hispanic populations throughout the U.S., raises challenges related to access and use of health services due to cultural competence among healthcare providers. These challenges become greater with an LEP person. For example, new Latino immigrants are reportedly less likely to have access to healthcare and healthcare resources than those who have been living in the United States for longer periods of time.6

Impact of Language on Healthcare Services

Language barriers for Hispanics who are not proficient in English are partly responsible for disparities in the healthcare services they receive in this country.7 Disparity in healthcare is present when health equity is absent. Concha (2018) defines health equity as the “attainment of the highest level of health for all people.”6 Health equity requires attention to biological, physical, social, cultural, and environmental factors that impact the health status of underserved communities and racial and ethnic minorities.6

When there are language barriers, disparities in healthcare may occur whether or not the person is comfortable speaking English.7 There are three mechanisms linked with language barriers that may lead to unequal access to healthcare: the ability to find or locate healthcare; communication difficulties with providers; and, a reduction in a person’s health care–seeking behavior.7 Of these three factors, communication difficulties may be the most important:

6 NurseCe4Less.com

quality patient-provider communication is associated with increased adherence to treatment, patient satisfaction, and overall enhanced health outcomes.6

The effects of LEP on health outcomes lowers the health levels of LEP persons. This impacts the admissions process,8 informed consent,9 discharge,10 services outside the hospital setting,11 and end-of-life decision making.12 Moreover, when people belonging to an ethnic minority in the U.S., encounter barriers to healthcare access, they are more likely to obtain health support from unlicensed resources or online searches that may be less reliable and inaccurate.6

Similar to the general population in the U.S., heart disease and cancer pose major risks for death among Hispanics or Latinos; however, these risks are even higher among Hispanics. Other significant health disparities have also been observed with Hispanic and Latinos, including higher rates of chronic diseases. They include diabetes, high cholesterol, asthma, and some cancers.13 Hispanic or Latina women, for example, carry a higher risk of death from breast cancer with a more advanced cancer stage seen at the time of diagnosis as compared to non-Hispanic White women because of lower rates of cancer screening.13 Moreover, Hispanic and Latina women are considered at higher risk of developing aggressive breast cancer than non-Hispanic White women.13 These trends coincide with lower adherence to cancer treatment, and limited access to quality healthcare.13

Aside from a lower response to recommended cancer screenings and other preventative healthcare seen in Hispanics and Latinos, other disparities include dental care, prenatal care, health insurance coverage, and ease of accessing needed or desired healthcare.13,15 Hispanics and Latinos are more likely to be overweight or obese and engage in less physical activity as compared with non-Hispanic Whites.6

Unnecessary diagnostic tests tend to occur more frequently in LEP patients than those who are English speaking because LEP patients are less able to report their symptoms accurately or they may misunderstand what the

7 NurseCe4Less.com

health provider advised. For example, a greater number of unnecessary tests, frequent visits, and higher healthcare costs were reported with LEP patients who utilized emergency department medical services, as compared with English speaking patients.16

Barriers to Healthcare Services for LEP Persons

Individuals with limited English proficiency experience barriers to equality in healthcare. These barriers are often linguistic and are caused by systemic or cultural impediments, or poor communication. Communication can be difficult even without the overwhelming issues that occur when a health problem arises but in healthcare, adverse outcomes such as missed interpretations and diagnoses, and higher costs can result from healthcare disparity.17

Systemic Barriers

Individuals with limited English proficiency in the U.S., have reportedly increased, as discussed above. Over 34% of them are insured under Medicare or Medicaid.9 This means that the Centers for Medicare & Medicaid Services is administering healthcare for this large number of LEP persons; however, it lacks the information necessary to meet their needs and preferences.9 This lack of information creates a structural or systemic barrier to healthcare access for Hispanic patients.9

Cultural Barriers

Impediments to health care access for Hispanics involve language and cultural barriers. They include inequality in health insurance markets. This may be due to employment that fails to provide adequate health benefits. Hispanic healthcare providers are underrepresented. Greater representation may provide greater cultural sensitivity to the needs of Hispanic LEP patients. Other barriers include geographic mobility and possibly, undocumented status.18

8 NurseCe4Less.com

Poor Communication

Communicating clearly and accurately in a healthcare setting is an important part of quality patient care. The Joint Commission has reported that failures in communication in U.S., hospitals and medical practices were partially responsible for 30% of malpractice claims.14 More specifically, in a study conducted by the Joint Commission, LEP patients who were treated in U.S., hospitals experienced adverse events at higher percentages than non-LEP patients who participated in the study: physical harm occurred with 49.2% of the LEP patients, compared to 29.5% of those who spoke English well; and, severe harm or death was suffered by 3.7% of LEP patients, compared to 1.4% of patients who spoke English well.14 These findings aligned with those reportedly by the United Nations Educational, Scientific, and Cultural Organization (UNESCO) Institute of Statistics that reported an estimated 750 million (16%) of adults worldwide lacked basic health literacy skills, and a Canadian study revealed that 60% of Canadian adults had limited health literacy, similar to trends seen in Europe, Australia, and Latin America.14

Governmental Requirements for LEP Patients

In 1964, the U.S. Congress enacted Title VI of the Civil Rights Act,

declaring that “no person in the United States shall, on the grounds of race, color, or national origin, be excluded from the participation in, be denied the benefits of, or e subjected to discrimination under any program or activity receiving federal assistance.”19 According to the Agency for Healthcare Research and Quality (AHRQ), Title VI also bars discrimination against a person based on their primary language. This is enforced by the US Office for Civil Rights and Department of Health and Human Services (DHHS).20 This means that Federal law requires linguistic services for LEP patients.

Health agencies that receive U.S. Federal funds are required to make reasonable efforts to provide language services or interpreter services to LEP patients. The Joint Commission, the main hospital accreditation body in the U.S. requires the use of qualified medical interpreters for LEP patients. Specifically, Joint Commission regulations for accredited U.S., healthcare

9 NurseCe4Less.com

agencies require that interpretative services are staffed by individuals who are trained to provide such services like trained bilingual staff, contract interpreting services, and employed language interpreters.20 Such services will diminish patient nonadherence to treatment and improve patient satisfaction.1,6 Furthermore, interpreting services may be offered in person or via telephone or video.20

In order to reaffirm Title VI and further mandate equal access to healthcare for individuals with LEP, Executive Order No. 13,166 was signed in 2000. The Order helped improve access to healthcare for LEP persons at no cost to the patient.21

In addition to federal laws, states have also enacted laws encouraging

and mandating access to healthcare for LEP persons. According to Youdelman (2019), the 50 states and the District of Columbia have enacted laws addressing language access.22 State laws vary greatly in their scope. California has extensive laws dealing with healthcare access for LEP persons but most states have more limited laws that target specific healthcare providers, services, or patient groups. Some states provide detailed guidance, while others recognize the importance of access for LEP patients but do not offer guidance on how this should be done. State laws tend to be directed toward private insurers, competency of interpreters, and training in cultural competency for health professionals.22

Preventing Disparities in Healthcare

Healthcare for certain sectors of LEP, Spanish-speaking patients has

improved; however, reports continue to be mixed with variable outcomes based on study design and population.23 This emphasizes the need to continue efforts to reduce disparity in healthcare for Hispanics in the U.S.

There are a number of ways a clinician can improve healthcare outcomes for LEP, Spanish-speaking patients. Improved outcomes begin with good communication. Providers may improve communication using technology, translation apps, interpreters, and services for LEP who are hearing impaired.

10 NurseCe4Less.com

Good Communication

Disparities in healthcare can be reduced through good communication. As mentioned above, federal law requires that LEP patients must be provided with options to communicate health needs in a safe and appropriate manner.1 Karliner (2018) highlighted options published by the Agency for Healthcare Research and Quality (AHRQ) to ensure language provisions are offered to LEP patients, such as communicating through an in-person, telephonic, or video interpreter if those resources are available during a clinical encounter.

According to the Joint Commission (2021), it is recommended that health organizations should have a process to ensure that communication with LEP patients is effective and designed to address their needs.24 For example, the organization can determine if a language proficiency assessment is necessary and to ensure a bilingual provider can communicate effectively or is able to consider the use of an interpreter to validate the patient's understanding of the information provided.24 In addition, there is no prohibition that a bilingual practitioner cannot communicate directly with a patient in the patient’s language while providing care, treatment or services.24 Use of an Interpreter Services

Communicating with patients and families in their language in the healthcare setting is important. If possible, a provider should use a telephone interpretation service or have a medical interpreter on site.

Family members, friends, or ad hoc interpreters may be needed in certain situations (e.g., in an emergency and there are no available alternatives) but there are limitations to their usefulness in complicated or emotive situations. Although a patient may feel more comfortable and be more consoled by the presence of a familiar interpreter, strong consideration needs to be given to accurate interpretation in communicating a health-related issue.17 Professional healthcare interpreters are specifically trained to address sensitive and complicated topics.17 Family members may become emotionally distressed at receiving upsetting medical news and may incorrectly interpret

11 NurseCe4Less.com

information or become unable to continue interpreting. A qualified medical interpreter can be more impartial when relating sensitive health information.25 Generally, children under 18 years of age should not be used as interpreters in any context.25

Some tips to keep in mind when working with an interpreter include:25

● Sit facing the person ● Look at the person and maintain awareness of body language ● Avoid looking at the interpreter unless that person is being directly

addressed ● Speak directly to the person as with an English speaker ● Always use the second person; e.g., “How are you feeling?” Not the third

person, e.g., directed to the interpreter, “Ask her how she is feeling?” ● Do not try to save time by asking the interpreter to summarize ● Be aware that it may take more words than spoken to convey the message ● Do not let the interpreter’s presence change the clinician’s role in the

conversation ● It is not the interpreter’s role to lead the discussion

During a clinical encounter with the LEP patient, there must be time allowance for frequent pauses between speaking to ensure the patient is receiving an accurate interpretation.1 Commonly used Spanish phrases may be learned by health professionals to use in situations with Spanish-speaking patients and families when an interpreter is not available. A high risk of error exists when clinicians are communicating with LEP patients without a qualified professional interpreter.25 If an interpreter is not available, the health professional will have to use other resources available to communicate with the Spanish-speaking patient and/or family. Use of Media and Technology

Concha (2018) argues that Hispanics and Latinos in the U.S., who have gone without regular access or contact with a healthcare provider should receive specific support, which includes continuous monitoring of the quality

12 NurseCe4Less.com

of Spanish-language correspondences, e.g., electronic text messages, emails, and or other logs and services. Concha emphasized: “Clinicians and researchers who utilize and study technology-based approaches to improving access to healthcare information and services should be cognizant that efforts to further health equity are complex and need to address a wide range of social, cultural, educational, and economic factors.”6

Clayman, et al. (2010) found that LEP Hispanics do not have the same

“trust and media use patterns” as do individuals who speak English well.26 They may not be receptive to Internet or print media that is text-based since this challenges their English proficiency.26 This suggests the LEP Hispanic patients may be more comfortable using “aural and visual channels (radio messages, television, family/friends, doctors).”26 The important point made by Clayman, et al., is that healthcare providers need to be flexible with the form of media they use, and find the media that works best for LEP populations.26

Another technology that may be considered is the use of virtual technology. One study evaluated the use of virtual technology in an emergency department to meet the communication needs of LEP patients during the COVID-19 pandemic.27 The form of virtual technology used was Interpreter on Wheels (IOW). A provider may access over 200 languages using IOW by subscribing to a service. Interpreter on Wheels uses an electronic tablet on wheels and has a secure audio amplification system. This technology uses a touch screen app. This service is available at all times and may be accessed using video or audio technology.27 The authors described patient and staff feedback as “extremely positive.”27 Several case examples of IOW usefulness included: ● Deaf male with hip pain: arrived with a notepad and pen ready to

communicate with ED staff and was “pleasantly surprised that we were able to access an American Sign Language video interpreter within seconds.”27 An accurate history, focused physical exam, and discharge instructions were effectively provided and his medical concerns were met.

13 NurseCe4Less.com

● Female patient with code status intervention: critical content for a sensitive conversation was needed with the use of medical and technical terms. End of life goals of patient care were effectively carried out including details of the patient’s medical prognosis. The patient and family members expressed appreciation of their care.27

● Male patient with symptoms of anxiety and insomnia: a detailed conversation was achieved with the use of IOW to “understand his concerns both physical and psychological.”27 Although the patient’s situation was complex and required varied and multiple conversations, the IOW allowed for an adequate treatment plan that included mental health follow-up in the outpatient setting.

Interpreter Phone Systems

Proctor, et al. (2018), referenced research by Lee, et al. (2017) that showed that Spanish-speaking and Chinese-speaking patients received improved informed consent for healthcare treatment when a bedside interpreter phone system was used.9,28 Additionally, reduced readmission rates and expenditures were associated with the use of interpreters.1 Among Hispanic patients, dosing errors in patients who may be LEP or have limited health literacy continue to be a high concern, and Proctor, et al., suggested an effort to “better characterize the LEP population may assist in reducing these errors.”9 Translation Apps

Panayiotou, et al. (2019) studied translation apps in Australia that were available commercially.29 Apps available for use on an iPad and at no cost were included, and the apps that were identified needed to be able to translate at least one of the top 10 languages spoken.29 Although the authors maintained a conservative approach with regard to the cautious use of iPad translation apps in healthcare settings and the essential requirement of professional interpreters, they noted that “some apps may be suitable for

14 NurseCe4Less.com

everyday conversations, such as those that enable preset phrases to be translated on subject matters that do not require a professional interpreter.”29

Allen, et al. (2020) focused on the critical importance of language,

interpretation, and translation for medical providers in the U.S. The authors stated that considering language needs during everyday clinical practice before a patient arrives for care can create a more holistic approach to language problems.17 They described a 360-degree model of the clinician, interpreter or translator and of the patient’s stressors; and, all complex factors affecting patient care outcomes when health providers do not share the same language as their patients: “linguistics, gesture, health literacy, health communication, and cross-cultural experience.”17

Allen, et al., suggest that interpretation involves two essential

characteristics: “First, it involves the rendering of live utterances in one language to live utterances in another language. The ‘source language’ is the language of the speaker (or signer). The ‘target language’ is the language of the receiver of the interpretation. Interpreting necessarily involves one of three possible dyads: (a) spoken source language and spoken target language, (b) spoken source language and signed target language, or (c) signed source language and signed target language. Second, interpretation, being a live act, necessarily involves an immediacy not characteristic of translation. That is, the interpreter has to process a piece of speech and render it — either simultaneously or consecutively — into the other language, without the opportunity to consider alternative renderings.”17

Simultaneous interpretation typically involves linguistic and cognitive challenges with a risk of interpretive inaccuracies leading to increased time delay between speech and interpretation.17 In their own language, the patient speaks (or signs), and the interpreter speaks aloud (or signs) what is said for the health provider to understand while attempting to understand what the patient is saying next.17 Simultaneous interpretation can improve if the interpreter has access to electronic media in advance of clinical care. With consecutive interpretation, the patient produces (or signs) a short sentence or two, pauses as the interpreter delivers the sentences to the health provider,

15 NurseCe4Less.com

and then continues to provide short sentences for the interpreter to deliver. Allen, et al., stated that consecutive interpretation “can be more precise and accurate than simultaneous interpretation because it gives the interpreter more time to seek an appropriate rendering and does not involve the cognitive challenge of undertaking the two tasks of listening and rendering at one time (as in simultaneous interpreting).”17 The authors explained that consecutive interpretation can also require more time as the patient must pause as the message is delivered by the interpreter to the recipient of the message (health provider).17

Sight Translation

Best translation involves an understanding of the “nuance and connotative power of both languages”17 appropriate to the target audience. Interpreters may also be required to provide a sight translation for longer and more complex documents, such as forms for informed consent, advance directives, and health educational materials, and these forms need to be translated prior to use. The interpreter must be able to speak and read in two languages or the interpreter runs the risk of inaccuracy, reduced clarity, and of limited communication between the health provider and LEP patient.29

Although a bilingual person is essential in these unique situations, not all bilingual persons can interpret.17

The requirements of professional interpreters involve in-depth training and skills in different languages and an ability to move between the different languages. Most professional interpreters hold master’s degrees that show years of required practice and proficiency to efficiently and accurately provide an interpretive service.17 Some interpretive services offer national certification but certification is not a requirement for all spoken languages.25 It is important for health clinicians to recognize that bilingual ability differs between persons, and that most bilingual persons can display varying levels of competency in language interpretation. The ability to translate and interpret two languages involves training and skill, and is not solely based upon being conversationally fluent in two languages.17

16 NurseCe4Less.com

When an in-person interpreter is unavailable, effective communication between provider and the LEP patient is possible through electronic means. Clinicians may discover that such devices may lack the precision and flexibility required for medical interactions, such as words spoken out of context or unfamiliar words can impair effective communication. Miscommunication can involve a range of words, such as the “use of ‘PAP,’ which can vary from ‘the common gynecological test of a PAP smear,” to “positive airway pressure,’ to ‘a synonym for soft or baby food’ ... Such a device could also have difficulty relaying like-sounding words such as dysphagia (difficulty in swallowing) and dysphasia (a brain injury that complicates communication or makes it impossible).”17 Although electronic means of communication for LEP patients are improving and offer a solution when professional interpreters are unavailable, the solution remains imperfect in certain medical situations and requires added checks and monitoring for quality outcomes. In planning ahead, the authors suggested that health teams continue to reflect upon best practice trends for LEP patients and on interpretation preparedness prior to patient arrival to a health agency.17

Kwok, et al. (2021) provided an example of a team-driven approach to

elicit administrative support and funding for their hospital in British Columbia (BC), Canada where an estimated 60,000 annual emergency department (ED) visits were reported with 76% being of a culturally diverse population.27 The authors reported on the lack of dedicated ED interpreters despite a high number of LEP patients who required interpretation services for safe and appropriate communication for their specific healthcare needs. They also raised the possible requirement to treat patients who were newly arrived from other countries through the BC International Airport where 25 million passengers from 100 countries passed through annually.27 Other issues of safety raised in the study included the removal of healthcare staff from their existing clinical duties due to the lack of a dedicated interpreter for ED patients. The use of an electronic device to link an LEP patient with an interpreter was studied in terms of efficacy to deliver safe and appropriate ED care, and relative to patient and healthcare staff satisfaction.27

17 NurseCe4Less.com

The authors conducted their study between 3/30/2020 and 5/31/2020 and reported a total of 477 virtual interpretation encounters in their ED during the COVID-19 pandemic requiring 4123 interpretation minutes (2835 audio minutes and 1288 video minutes) with a majority of the interpretation needs in their area being Mandarin or Cantonese.27 Of significance, the use of a dedicated interpreter through an electronic device was viewed as preventing ED misuse and requirements of soliciting ad hoc interpreters, concentrating more specifically on the clinical needs of ED patients. In the midst of the COVID-19 pandemic, infectious disease concerns were also reduced as a result of limited physical contact between patients and hospital staff who had been previously pulled into ad hoc interpretations for LEP patients. The satisfaction of patients was reportedly high with low negative feedback.27

The interpretation service was provided through a specific electronic

device used during the patient clinical assessment by members of the ED treatment team, e.g., physicians, nurses, social workers, counselors, respiratory therapists, pharmacy staff, and other support staff such as admission clerks. During the ED patient admission and discharge, critical functions involving the health history, medication reconciliation and education were carried out more effectively with the use of this electronic device allowing access to a dedicated interpreter.27

Cost was assessed that included an audio interpretation fee of

$0.90/min and a video interpretation fee of $1.60/min.27 Although the monthly cost was described as “significant” for their hospital, the potential cost of infectious disease exposure during the pandemic and unsafe conditions stemming from removal of ad hoc interpreters from important duties carried a higher cost in the event of an adverse outcome. Study limitations involved the restrictions of the pandemic itself and barriers relative to quantitative measures pertaining to interdisciplinary health team members’ experiences using the device during a two-month study limited to the ED.27

18 NurseCe4Less.com

Translations Versus Interpretations

Allen, et al., point out an important difference that can affect translation services, as compared to interpretation services. A person translating from one language to another may be different from the context where a person interprets dialogue from one person to another who speaks a different language. An interpreter is acting “live” and is more spontaneous, whereas a translation may not be live.17 A translation may occur over time; that is, a translator may be given time “to consider the input and output provided” since a translation may be “separated in time from the source material.”17

Referencing Youdelman’s position,22 the authors also stated that the “most qualified translators are those who write well in their native language and who have mastered punctuation, spelling and grammar. Translators know how to analyze a text and are keenly aware of the fact that translation does not mean word-for-word replacement, but that context is the bottom line for an accurate rendition of any text.”17 A level of flexibility and patience is required on the part of the healthcare provider in such situations.17 Sign Language for Hearing-Impaired Patients

Translations also exist between varying sign languages. Sign languages are not universal, and tend to require movement between a “recorded form of one language into a recorded — not necessarily the same form — of another language.”17 During either recorded spoken or signed language for the hearing impaired, communication could be via written text, audio recordings of spoken language, or video recordings.17

Therefore, translation for hearing impaired patients tends not to be

“live,” but entails longer time spans between the source production and the rendering into the target language.17 Allen, et al., stated that this time difference of a recorded language creates an opportunity for “consideration of alternative translations, research into previously produced translations, assistance from automatic translators by computer, and revision of the final target production.”17

19 NurseCe4Less.com

Case Scenario: LEP Female, Hispanic Patient

Karliner (2018) reported on a 56-year-old Hispanic woman with limited English proficiency. The clinical setting was a preoperative evaluation. She was meeting with her provider to prepare for an elective, abdominal hysterectomy and a bilateral oophorectomy.1 The provider was aware that the patient would need a Spanish-speaking interpreter to assist during her preoperative session.1

The patient arrived for her scheduled appointment. The physician in

attendance did not speak Spanish. An interpreter was not available and family members who had acted as an interpreter in the past were also unavailable. Under these circumstances, the provider decided to use a phone interpreter service. The service was available in audio format only. The quality of the audio was poor so the patient was not able to hear what the interpreter was saying very well.1 An assistant who worked for the provider was used as an interpreter because the phone interpreter service had limited success; however, the failures and limitations caused a scheduled 30-minute preoperative evaluation to take more than 75 minutes. The surgery had to be rescheduled because of the patient’s cardiac symptoms.1 In the end, the patient did not suffer an adverse outcome since the physician was able to determine that the patient’s cardiac symptoms required that the surgery be rescheduled; however, valuable time was lost and the patient was subjected to suboptimal experience due to LEP.1 This occurred because the facility did not have a process in place to identify LEP patients and to ensure that an interpreter would be present prior to scheduled appointments.1

Discussion

Karliner analyzed the case by looking at whether the legal requirements were net under Title VI, as well as the patient outcome.1 Karline reviewed the various interpretation modalities available.

In-person interpreters are preferred but it is acknowledged that a medical facility cannot have an in-person interpreter for every language.1

20 NurseCe4Less.com

Clearly medical providers would want to staff interpreters for the prevalent non-English languages in their community, but Karliner suggests that a mix of modalities is probably better if the provider wants to cover more LED populations.1

Telephone interpretation services or video-conferencing services are modalities that may be added to in-person interpreters that a provider has on staff.1 This expands language coverage and offers an “economy of scale” since these companies are independent contractors who may serve multiple healthcare providers.1 These services save time, resources and provides “on-demand” language services.1 The importance of multiple options was seen with this case since the failure of the audio telephonic, and video-conferencing as a backup would have been more optimal. Video-conferencing can be even better if a provider is able to utilize or invest in video medical interpretation or video remote interpretation technology.1

Basic Interview: Questions and Engagement

Greetings and Farewells

Good morning Buenos días

Good afternoon Buenas tardes

Good night Buenas noches

Hi Hola

Goodbye Hasta luego

Sir Señor

Ma'am Señora

Miss Señorita

21 NurseCe4Less.com

Social Courtesy

Please Por favor

Thank you Gracias

You're welcome De nada

I'm sorry Lo siento

How are you feeling today? Cómo te sientes hoy?

Are you feeling better? Te sientes mejor?

Have a good day Que tengas un buen día

Excuse me Perdón

Introductions

I'm the nurse Soy la enfermera (female) Soy el enfermo (male)

I’ll be taking care of you today Estare quidando de ti hoy

My name is _______. Mi nombre es--_______.

What's your name? Cuál es tu nombre?

Nice to meet you Mucho gusto.

Please sit down Por favor, siéntese

This is the nurse's aide Este es el ayudante de la enfermería (female) Este es el ayudante del enfermo (male)

This is the doctor Este es el doctor

Do you need an interpreter? Necesitas un intérprete?

22 NurseCe4Less.com

Orientation

Do you know where you are? Sabes dónde estas?

Do you know why you are here? Sabes por qué estás aquí?

What day is it? Qué día es hoy?

What month is it? Qué mes es?

Orientation to Health Unit

This is your room Este es tu cuarto

This is your bed Esta es tu cama

This button will raise and lower the bed Este botón sube y baja la cama

Please keep the side rails up Por favor, tenga las barandas arriba

Push this button if you need help Pulse este botón si necesitas ayuda

The telephone is here El teléfono está aquí

Here's the control for the television Aquí está el control de la televisión

The bathroom is here El baño está aquí

Clarifying Communication Needs

Do you speak English? Hablas Inglés?

I don't speak Spanish Yo no hablo español

I only speak a little Spanish Yo sólo hablo un poco de español

Do you understand? ¿Me entiendes?

I don't understand No entiendo

Repeat that, please Repita eso, por favor

23 NurseCe4Less.com

Please, only answer "yes" or "no" Por favor, sólo responda sí o no

Speak very slowly, please Por favor, hable despacio

Family Relations

Do you have children? Tienes hijos?

What's your relation to the patient? Cuál es su relación con es la paciente? (female) Cuál es su relación con es el paciente? (male)

Is he your son? Él es su hijo?

Is she your daughter? Ella es su hija?

Are you her husband? Es usted el esposo de ella?

Are you his wife? Es usted la esposa de él?

Is he your brother? Él es tu hermano?

Is she your sister? Ella es tu hermana?

Obtaining Vital Signs

I'm going to measure your blood pressure

Voy a medir tu presión arterial

I'm going to measure your temperature Voy a medir tu temperatura

I'm going to measure your pulse Voy a medir el pulso

I'm going to listen to your lungs Voy a escuchar a los pulmones

Breathe deeply, please Respire profundamente, por favor

I'm going to listen to your heart Voy a escuchar a tu corazón

Everything is normal Todo es normal

24 NurseCe4Less.com

Ambulation

I'm going to help you get into the chair Te voy a ayudarte a sabir en la silla

Hold on to me Aférrate a mí

I want you to stand up Quiero que tú te levantes

Hold the walker Sostenga el andador

Let's walk down the hallway Vamos a caminar por el pasillo

I won't let you fall Yo no te voy a dejar caer

Don't get out of bed without help No salga de la cama sin ayuda

You can't walk by yourself No se puede caminar por sí mismo

Changing Position

Turn on your right side Gire a tu derecha

Turn on your left side Gire a tu izquierda

Turn onto your back Gire en tu espalda

Sit up Siéntese

Sit on the side of the bed Siéntese al lado de la cama

Stand up Levántese

Basic Instructions

Breathe in Inhale

Breathe out Exhale

Cough Tosa

Take this medicine Tome este medicamento

25 NurseCe4Less.com

Listen to me, please Escúchame, por favor

Lie down Acuéstese

Be careful Ten cuidado

Swallow Trague

Open your mouth Abre la boca

Don't move No te muevas

Pay attention Preste atención

Medications

Do you have allergies? Tiennes allergos?

Are you currently taking any medications?

Estas tomando alguna medicación?

Take this pill Tome esta pastilla

This is for the pain relief Esto es para alivio el dolor

You need an antibiotic Usted necesita un antibiótico

I'm going to give you an injection Te voy a poner un inyección

There will be a little pain now Habra un poco de dolor ahora

Comfort

Are you having trouble breathing? Tiene problemas para respirar?

Did you sleep well? Dormista bien?

Are you cold? Tienes frío?

Are you hot? Tienes calor?

26 NurseCe4Less.com

Do you need another blanket? Necesitas otra cobija?

Would you like another pillow? Quieres otra almohada?

Are you in pain? Tienes dolor?

Where does it hurt? Dónde te duele?

Touch the spot where it hurts. Toca el lugar donde duelo.

Toileting and Hygiene

Did you have a bowel movement? Teviste una evacuación intestinal?

I’m going to clean you. Te voy limpiar.

I’m going to bathe you. Voy a bañarte.

Can you raise your arms? Puedes levantar los brazos?

Do you need to use the bathroom? Necesitas usar el baño?

Nutrition

Are you hungry? Tienes hambre?

Are you thirsty? Tienes sed?

Do you have problems chewing? Tienes problemas para masticar?

Do you have problems swallowing? Tienes problemas para tragar?

Encouragement/Support

You’ll be leaving the hospital soon! Pronto saldrás del hospital!

You’re doing great! Lo estás haciendo genial!

Sleep well! Dormir bien!

27 NurseCe4Less.com

You’re looking much better! Te ves mucho mejor!

Assessing Comfort

Are you hot? Tienes calor?

Are you cold? Tienes frío?

Do you feel OK? Te sientes bien?

Do you feel sick? Te sientes enfermo/a?

Are you feeling better? Te sientes mejor?

Are you feeling worse? Te sientes peor?

Dressing

Change into this hospital gown Ponte esta bata de hospital

Numbers

Zero Cero

One Uno

Two Dos

Three Tres

Four Cuatro

Five Cinco

Six Seis

Seven Siete

Eight Ocho

28 NurseCe4Less.com

Nine Nueve

Ten Dez

Twenty Veinte

Thirty Treinta

Forty Cuarenta

Fifty Cincuenta

Sixty Sesenta

Seventy Setenta

Eighty Ochenta

Ninety Noventa

Hundred Cien

Having a few simple phrases memorized or archived in an accessible notepad or electronic device can help the healthcare clinician to obtain needed introductory information from the patient with limited English proficiency. A reference to some basic phrases and/or questions can support LEP patients to communicate basic needs when an interpreter is unavailable. Messias, et al. (2017) reported on helpful technology-based approaches in anticipation of common constraints and barriers encountered by LEP patients and to potentially mitigate disparities in healthcare.30 National-level data for accessing and utilizing technology (e.g., computers, internet, cellular phones) are available for Hispanics/Latinos seeking healthcare information. However, these data may not reflect the specific situations of Hispanics/Latinos residing in remote geographic areas or rural communities where access to technology and health resources are limited as compared with their urban counterparts.30

A better understanding of technology utilization in relation to healthcare access is needed to determine the appropriateness and feasibility of

29 NurseCe4Less.com

technology-based approaches for improving health information access and healthcare services for Hispanic/Latino communities. Providing culturally and linguistically appropriate health information through accessible technology is one approach for healthcare providers and organizations when addressing health literacy and attempting to enhance appropriate and timely access to healthcare among LEP populations.31

Further research is warranted to identify best practices for utilizing

communication technologies to enhance access to healthcare information and services among LEP populations. Ongoing efforts by policymakers, researchers, clinicians, educators, librarians, and community outreach workers to enhance access to healthcare information and services are essential for achieving health equity within the Hispanic/Latino community. Clinicians and researchers who study technology-based approaches to improving access to healthcare information and services should be cognizant that efforts to improve health equity are complex and involve a wide range of social, cultural, educational, and economic factors.

Summary

The demographics of the U.S. are changing and the Spanish language is becoming increasingly important in order to provide safe and appropriate healthcare in varied U.S. regions. Recognizing and understanding how language barriers influence healthcare access is a necessary starting point to provide access to healthcare for LED. Healthcare providers can consider their potential role in eliminating this barrier and decreasing health disparities. With an appreciation of the role language barriers play in healthcare disparities, clinicians can address the degree of cultural relevance in the design and delivery of healthcare services to ethnic minority populations whose primary language is not English. When there are language barriers, disparities in healthcare may occur whether or not the person is comfortable speaking English.

Barriers to health equity are often linguistic and are caused by systemic or cultural impediments, or poor communication. There are three mechanisms

30 NurseCe4Less.com

linked with language barriers that may lead to unequal access to healthcare: the ability to find or locate healthcare; communication difficulties with providers; and, a reduction in a person’s health care–seeking behavior. There are a number of ways a clinician can improve healthcare outcomes for LEP, Spanish-speaking patients. Improved outcomes begin with good communication. Providers may improve communication using technology, translation apps, interpreters, and services for LEP who are hearing impaired. Having quick access to basic Spanish conversational phrases and questions are also useful to health clinicians in situations involving Spanish-speaking patients and families when an interpreter is not available.

31 NurseCe4Less.com

Course Test 1. Health equity means that all people, regardless of ethnicity, race

or status,

a. will have a positive outcome to any health issue. b. can attain the highest level of health. c. will have a healthcare provider who speaks their language. d. receive the same healthcare services and treatments.

2. The terms “Hispanic” and “Latino”

a. are not the same. b. mean the same thing. c. refer to individuals from Spain. d. refers to people from Spain and Rome respectively.

3. The Latino population is expected to make up ______ of the total

population of the United States by the year 2060.

a. one-tenth b. one-third c. 26.5% d. 50%

4. The effects of limited English proficiency (LEP) on healthcare

services can impact

a. the admissions process. b. patient discharge. c. end-of-life decision making. d. All of the above

5. True or False: Disparities in healthcare do not occur with LEP

persons who are comfortable speaking English.

a. True b. False

32 NurseCe4Less.com

6. “Necesitas un intérprete?” means in Spanish:

a. Is your niece the interpreter? b. Where is your necessary interpreter? c. Do you need an interpreter? d. Do you need more than one interpreter?

7. Which of the following statements represents a cultural barrier to

healthcare services for Hispanics in the United States?

a. Language translators are not effective in Hispanic communities b. Certification of Hispanic translators is required c. Medicare/Medicaid does not have adequate records of Hispanic LEP

patients d. Hispanic healthcare providers are underrepresented in medicine

8. True or False: Health agencies that receive U.S. federal funds are

required to provide language services or interpreter services to LEP patients.

a. True b. False

9. Healthcare agencies receiving funds from the federal government

must have interpretative services that are

a. staffed by trained individuals; e.g., trained bilingual staff. b. provided by independent contractors. c. offered in person only. d. All of the above

10. Language translations can differ from the situation where a

person acts as an interpreter because

a. translators are required to be certified but interpreters are not. b. interpreters perform their tasks live whereas a translation may be

done over time. c. interpreters only need to be proficient in the target language. d. interpreters must be masters of punctuation, spelling and grammar.

33 NurseCe4Less.com

11. Family members of a patient should not act as an interpreter in a medical setting because

a. HIPAA rules prohibit them. b. family members may become emotionally distressed by a loved

one’s negative medical news. c. they are never impartial when interpreting medical news. d. All of the above

12. Some tips to keep in mind when working with an interpreter

include:

a. Allow the interpreter to lead the discussion. b. Speak directly to the interpreter to avoid confusion. c. Sit facing the interpreter. d. Always use the second person; e.g., “How are you feeling?”

13. According to Clayman, et al., when comparing LEP Hispanics to

individuals who speak English well, LEP Hispanics

a. are less comfortable with aural and visual channels. b. are not impacted by immigration status. c. do not have the same trust and media use patterns. d. are less likely to experience inequality with health insurance.

14. True or False: When an in-person interpreter is unavailable,

effective communication between provider and the LEP patient is not possible.

a. True b. False

15. Translations between sign languages

a. tends to be live just like spoken languages. b. is simplified by the fact that they are universal. c. could be communicated via written text. d. cannot be communicated using audio recordings.

34 NurseCe4Less.com

References 1. Karliner LS. When Patients and Providers Speak Different Languages.

Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. 2018. Retrieved from https://psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages

2. United States Census Bureau. People that Speak English Less Than "Very Well" in the United States. U.S. Census Bureau. 2020. Retrieved from https://www.census.gov/library/visualizations/interactive/people-that-speak-english-less-than-very-well.html

3. Caballero AE. Understanding the Hispanic/Latino patient. Am J Med. 2011 Oct;124(10 Suppl):S10-5. doi: 10.1016/j.amjmed.2011.07.018. PMID: 21939793.

4. Noe-Bustamante, Luis, et al. U.S. Hispanic Population Surpassed 60 Million in 2019, but Growth Has Slowed. Pew Research Center. 10 July 2020. Retrieved from www.pewresearch.org/fact-tank/2020/07/07/u-s-hispanic-population-surpassed-60-million-in-2019-but-growth-has-slowed/

5. United States Census Bureau. Hispanic Population to Reach 111 Million by 2060. October 9, 2018. Retrieved from https://www.census.gov/library/visualizations/2018/comm/hispanic-projected-pop.html

6. Concha JB. Approaches to Enhancing Patient-Centered Communication In Caring For Hispanic/Latino Patients With Diabetes. JCOM. 2018;25(3).

7. Cheng EM, Chen A, Cunningham W. Primary Language and Receipt of Recommended Health Care Among Hispanics in the United States. J Gen Intern Med. 2007;22(S2):283–288.

8. 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. 2015;30(6):783-789. doi:10.1007/s11606-015-3213-x

9. Proctor K, Wilson-Frederick SM, Haffer SC. The Limited English Proficient Population: Describing Medicare, Medicaid, and Dual Beneficiaries. Health Equity. 2018 2:1, 82-89.

10. Karliner LS, Auerbach A, Nápoles A, et al. Language barriers and understanding of hospital discharge instructions. Medical care. 2012;50(4):283.

11. Linderoth G, Hallas P, Lippert FK, et al. Challenges in out-of-hospital cardiac arrest - A study combining closed-circuit television (CCTV) and medical emergency calls. Resuscitation. 2015;96:317–322.

12. Barwise AK, Nyquist CA, Espinoza Suarez NR, et al. End-of-Life Decision-Making for ICU Patients With Limited English Proficiency: A

35 NurseCe4Less.com

Qualitative Study of Healthcare Team Insights. Crit Care Med. 2019;47(10):1380-1387. doi:10.1097/CCM.0000000000003920

13. Zavala VA, Bracci PM, Carethers JM, et al. Cancer health disparities in racial/ethnic minorities in the United States. Br J Cancer. 2021;124, 315–332. doi.org/10.1038/s41416-020-01038-6

14. Joint Commission International. Communicating Clearly and Effectively to Patients. How to Overcome Common Communication. Challenges in Health Care. A White Paper by Joint Commission International. 2018.

15. Velasco-Mondragon E, Jimenez A, Palladino-Davis AG, Davis D, Escamilla-Cejudo JA. Hispanic health in the USA: a scoping review of the literature. Public Health Rev. 2016;37:31. Published 2016 Dec 7. doi:10.1186/s40985-016-0043-2

16. Joint Commission International. Communicating Clearly and Effectively to Patients. How to Overcome Common Communication. Challenges in Health Care. A White Paper by Joint Commission International. 2018.

17. Allen, M. P., R. E. Johnson, E. Z. McClave, and W. Alvarado-Little. 2020. Language, interpretation, and translation: A clarification and reference checklist in service of health literacy and cultural respect. NAM Perspectives. Discussion Paper. National Academies of Medicine, Washington, DC. https://doi.org/10.31478/202002c

18. Brooks LA, Manias E, Bloomer, MJ. Culturally sensitive communication in healthcare: A concept analysis. Collegian. 2019;26(3), 383-391.

19. 42 U.S.C., §  2000d 20. Agency for Healthcare Research and Quality. Race, Ethnicity, and

Language Data: Standardization for Health Care Quality Improvement. Chapter 4: Defining Language Need and Categories for Collection. AHRQ. 2018. Retrieved from https://www.ahrq.gov/research/findings/final-reports/iomracereport/reldata4a.html

21. Executive Order 13166. Improving Access to Services for Persons with Limited English Proficiency. United States Department of Justice. Retrieved from https://www.justice.gov/crt/executive-order-13166

22. Youdelman M. Summary of State Law Requirements Addressing Language Needs in Health Care. National Health Law Program. 2019. Retrieved from https://healthlaw.org/resource/summary-of-state-law-requirements-addressing-language-needs-in-health-care-2/

23. Larson K, Cull WL, Racine AD, Olson LM. Trends in Access to Health Care Services for US Children: 2000–2014. Pediatrics. 2016;138(6) e20162176. doi: 10.1542/peds.2016-2176

24. The Joint Commission. Language Access and Interpreter Services – Understanding The Requirements. Print.2021. What are the key points organizations must consider when interpreter services are provided by staff and practitioners? 2021.

36 NurseCe4Less.com

25. Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician. 2014;90(7):476–80.

26. Clayman ML, Manganello JA, Viswanath K, Hesse BW, Arora NK. Providing health messages to Hispanics/Latinos: understanding the importance of language, trust in health information sources, and media use. J Health Commun. 2010;15 Suppl 3(Suppl 3):252-263. doi:10.1080/10810730.2010.522697.

27. Kwok MMK, Chan RK, Hansen C, et al. Access to Translator (AT&T) project: Interpreter on Wheels during the COVID-19 pandemicBMJ Open Quality 2021;10:e001062. doi: 10.1136/bmjoq-2020-001062

28. Lee JS, Pérez-Stable EJ, Gregorich SE, et al. Increased access to professional interpreters in the hospital improves informed consent for patients with limited English proficiency. J Gen Int Med. 2017;32:863–870.

29. Panayiotou A, Gardner A, Williams S, et al. Language Translation Apps in Health Care Settings: Expert Opinion. JMIR Mhealth Uhealth. 2019;7(4):e11316. Published 2019 Apr 9. doi:10.2196/11316

30. Messias DKH, Estrada RD. Patterns of Communication Technology Utilization for Health Information Among Hispanics in South Carolina: Implications for Health Equity. Health Equity. 2017;1(1):35-42. Published 2017 Jan 1. doi:10.1089/heq.2016.0013

31. Parés-Avila J, Sobralske MC, Katz JR. No comprendo: Practice considerations when caring for Latinos with limited English proficiency in the United States health care system. Hispanic Health Care International. 2011;9(4):159–167

The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NurseCe4Less.com.

The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare.

The information provided in this course is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals.

Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication.

Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold NurseCe4Less.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication.

The contents of this publication may not be reproduced without written permission from NurseCe4Less.com.