Open to Interpretation

In an increasingly multicultural, multilingual America, language barriers can get in the way of good health care. In fact, according to a report developed by the American Institutes for Research for the federal Office of Minority Health (OMH), there is a clear link between health care professionals’ ability to communicate with non-English-speaking or limited-English-proficiency (LEP) patients and families and the health care access these groups experience.

“For example, language barriers have led to fewer physician visits and reduced receipt of preventive services among LEP patients, even after considering factors such as literacy, health status, health insurance, regular source of care and economic indicators,” the OMH report, titled A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations, states. “Conversely, the use of clinical and preventive services has increased when professional interpretation services were provided.”

Other research indicates that language barriers can lead to inefficient use of health care resources, says Berta Cevallos, coordinator of the special needs/language assistance program at Southside Hospital in Bay Shore, N.Y.

“There have been studies showing that LEP patients are over-tested in the emergency room,” she explains. “They are over-medicated and they stay longer in hospitals. [Health care facilities] are using more resources to take care of them, but they are not really getting better and it’s because of the language barrier.”

Carol Bloch, MEd, MSN, RN, CTN, CNS, who along with her sister Carolyn Bloch, MEd, MSN, RN, CTN, CNS, is a transcultural nurse based in Los Angeles, says nurses have been at the forefront of the linguistic competency movement in the health care industry. The Blochs have taught introductory courses in medical Spanish to nurses and other clinical staff and have given educational presentations on the importance of cultural and linguistic competency in nursing. “Our goal is to give culturally congruent, culturally sensitive care,” Carol Bloch says.

“Caring, obviously, is the foundation for nursing,” says Rudy Valenzuela, MSN, RN, FNP-C. Language is one of the primary ways to communicate caring, according to Valenzuela, a nurse practitioner and author of the pocket reference book Spanish for Nurses, which was first published in April 2007 and recently went into a second edition. “To do a [treatment] or a procedure without communicating [with the patient] will be perceived as a lack of caring.”

Valenzuela, a past president of the National Association of Hispanic Nurses, is the current president and CEO of ESP Health Ministries at Camillus Health Center in San Luis, Arizona. Spanish-speaking patients seek him out when they come to the facility.

“Although I am a nurse practitioner and not a physician, [these patients] look for me–first of all, because I can communicate with them in their language, and secondly, because [they know] I will care for them [in a culturally competent way],” he says.

Assessing the Need

Developing language access services (LAS) to better serve a diverse population begins with each health care facility carefully assessing its patients’ needs. Generally, a hospital’s registration staff is charged with screening patients for language needs and preferences, says Catherine West, RN, MS, quality improvement specialist for Speaking Together: National Language Services Network, a national initiative working to improve the quality and availability of health care language services for LEP patients. The program, which combines quality improvement (QI) techniques with hospital-based LAS activities, initially began as an 18-month (November 2006 to May 2008) collaborative learning network of 10 acute-care hospitals around the country.

Discussions among the Speaking Together participants revealed a common problem with depending on the registration desk to handle linguistic screening: Registration staff were not always comfortable with the task and would often skip asking questions about language if the patient seemed fairly fluent in English.

“One of the main things [our program participants] did was to work with their registration staffs to create scripts on how to ask the questions and how to respond to the patient,” says West, who is on the faculty at George Washington University Medical Center, School of Public Health & Health Services in Washington, D.C. “The registration staff were very concerned about being sensitive and didn’t want to offend the patients in any way. Our participants created a script to ask, ‘What language do you want to speak to your doctor or nurse in,’ rather than asking, ‘What is your primary language,’ which is a question that people don’t really understand.”

Funded by the Robert Wood Johnson Foundation, Speaking Together used a very competitive process for selecting the participating hospitals, which were required to have language services programs already in place. “We didn’t want [hospitals that weren’t doing any LAS activities], because we wouldn’t have been able to learn from them,” West explains.

Among the best practices shared during the collaborative discussions was one hospital’s formation of a volunteer team of special nurse advocates for language access services. “One of our hospitals created a cadre of about 10 to 14 nurse champions,” West says. “It was such a wonderful thing, because all of these nurses volunteered and had an interest [in improving language services]. They all were trained in why this was important and what the options were. They became the unit experts [on linguistic competence].”

Choosing an Approach

Health care facilities can employ a range of methods to provide language access, including on-site medical interpreters, telephone interpreter services, video medical interpreting services, translators and translation software for written materials, bilingual clinical staff, and language classes for staff. How do you decide which approach, or combination of approaches, is right for your facility? Here’s a look at the pros and cons of some of these options.

Telephone interpreting may offer the broadest access in terms of the number of languages available. While Southside Hospital uses on-site interpreters for its large Spanish-speaking patient population, those preferring other languages can access telephone interpreting services through about 60 dual-handset phones located throughout the facility. “Once the patient identifies the language, we dial into the service and are in contact with an interpreter,” Cevallos says.

This method does present a couple of potential drawbacks, however. West cautions that before implementing such a program, it’s essential to get input from nurses, physicians and other staff about what kind of equipment will work best in a particular unit or work environment.

“Some hospitals simply increased the number of telephones that they had available, but they didn’t involve the people who were going to use the phones, like the doctors and the nurses,” says West. She recalls a group of Speaking Together participants who made up a cartoon to illustrate the dilemma. “It had a picture of a doctor gowned, gloved and masked—obviously ready for work in a sterile environment. And then here’s the phone with the doctor holding it, saying, ‘This isn’t exactly what I had in mind.’ What [that hospital] learned was that they had to involve the people in the units to find out what phones they needed and in what circumstances headphones or speaker phones would work best.”

One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations, a 2008 study published by the Joint Commission, points out another way that telephone interpreting can miss the mark.

“One caveat to using the telephone for providing interpreter services is that the interpreter misses nonverbal communication between the patient and provider,” the study says. “Hospitals may want to define, through organizational policies or procedures, which situations are appropriate for telephonic interpreting and which require direct interaction.”

Person to Person

On-site medical interpreters can provide the kind of face-to-face, personal connection that is lacking in telephone interpreting. Southside Hospital employs eight Spanish-speaking interpreters in a program implemented five years ago.

“We are the only hospital on Long Island that provides [interpreter services] on site, and one of the very few in New York state,” says Cevallos, who spent many years as a certified court reporter before being tapped to create the hospital’s language services program.

Southside is in the process of developing a new screening process to improve the way it identifies patients’ language needs. “The fact that patients have a [primary language other than English] does not necessarily imply that they need an interpreter,” Cevallos points out. “So we ask two questions: ‘What is your primary language?’ and ‘Do you need an interpreter?’”

Another challenge, she says, is that medical interpreting is a relatively new field for which few people have received specialized training, and in which there are no uniform standards for qualification. There is some work under way toward creating a national system for certification, she adds.

In the meantime, Cevallos has developed her own criteria to help select the interpreters under her charge. While a high level of fluency is important, a strong sense of ethics is even more essential. “Ethics is the heart of the medical interpreting career,” she emphasizes. “No matter how rich your knowledge is in medical terminology or languages, if you don’t have ethics the entire perception of the interpretation may change.”

She has even had to fire interpreters for unethical behavior, including one case in which the interpreter tried to interfere with an adoption. “It went against her own perceptions about life: ‘Why would you give away your baby? There are so many services here,’” Cevallos recounts.  “And she tried to convince the patient not to give the baby up for adoption.
“The power that interpreters have is immense,” Cevallos continues. “I can make someone consent or refuse based on the words that I choose to say, or my facial expressions or the tone of my voice.”

Culture and Language

Carolyn Bloch says interpreters must also be aware of how cultural differences can affect the communication between patient and health care provider when discussing medical concepts. “You need to make sure that the words you are using to explain a symptom are understandable in the patient’s culture,” she notes.

By the same token, Carol Bloch says a culturally knowledgeable interpreter can help the care provider understand the cultural nuances of what the patient is saying. For example, if a patient presents with what is known as “folk disease pathology,” the underlying medical problem can get lost in the translation. To illustrate, Bloch’s sister, Carolyn, chimes in with the example of the “evil eye.”

“It’s not a Western definition of a disease, but many patients feel that they’ve been hexed,” she explains. “Many cultures believe in witchcraft and those kinds of things. The patient comes in with real signs and symptoms and the interpreter is uncomfortable to say that this person feels he has been hexed by a witch. But in order for [nurses] to take care of them, we need to understand the whole cultural world view of the patient.”

The Blochs add that establishing trust is key when working through an interpreter to communicate with LEP patients and their families. Acknowledge and greet everyone in the room, Carol Bloch advises. If you take a moment to introduce yourself, ask patients about their families and begin to make them feel at ease, they are more likely to share the information you need to assess their medical condition. And one more thing, she says: “When you are talking, look at the patient. Don’t look at the interpreter.”

High-Tech Interpreting

For situations in which having an interpreter by the patient’s bedside isn’t an option, or an interpreter is not readily available, video medical interpreting (VMI) may offer a viable alternative. As the Joint Commission study points out, VMI has a notable advantage over distance interpreting via telephone: “The video component adds another level of information to distance interpreting, as interpreters are able to better see nonverbal behaviors communicated by patients and staff.”

The study goes on to note that some hospitals have used VMI to make their interpreters more efficient by eliminating the time they spend going from patient to patient for on-site interpreting sessions.

Asoperations and nursing director for primary care clinics, medical specialties, urgent care and language services at San Francisco General Hospital, Gloria Garcia-Orme, RN, MS, is in charge of implementing the hospital’s videoconferencing medical interpretation program. For years, in-person staff interpreters provided the primary means of language access services at the hospital.

“For quite some time this method was adequate,” Garcia-Orme says. “However, the volume of LEP patients served [by the hospital] continues to grow. Consequently, even with a significant investment in staff interpreter resources, the average wait time for an interpreter was becoming unacceptably long.”

The hospital conducted a VMI pilot program in 2002 and began a staged, facility-wide implementation in 2004. The results have been positive in two key respects, Garcia-Orme reports.

“Video interpretation maintains the body language cues that are important in nuanced communications,” she says. “Additionally, it results in dramatic reduction of average waiting time for interpretation services, due to the fact that interpreters no longer have to travel to the clinics and wait around for the providers to be ready. In [our] case, the average wait time for an interpreter has gone from well over 30 minutes to less than five minutes.”

Measuring Linguistic Competency

In West’s view, one of the most important contributions of the Speaking Together project has been to introduce ways to measure how well hospital language access programs are working. Speaking Together recently published a set of five language services performance measures, tested and implemented by its learning network hospitals.

“There have never been measures for language service improvement utilized on a national scale,” she says. “Generally, what hospitals measure in terms of language service delivery is that the interpreter department or some equivalent department will report on the number of encounters that they’ve performed.”

Far beyond merely tallying those numbers, participants in Speaking Together now have tools to help show whether patients received services that met their language needs.

More information about best practices for improving linguistic competency that emerged from the Speaking Together collaborative learning project is available online at www.speakingtogether.org. The Web site offers a variety of free resources and publications, including Tools for Improving Language Services Delivery, hospital success stories and a downloadable video, “How Effective Medical Interpretation Can Improve Quality of Care.”