Situations like this will continue to increase with the growth of a U.S. population that does not speak any English or speaks "less than very well." According to 2005 census data, this group is composed of about 23.1 million people compared to 13.9 million in 1990.¹ According to the self-reported assessment of the almost 52 million people who speak a language other than English at home from the 2005 census, 8.6% speak English with difficulty or not at all. This increase in the number of limited English speakers is expected to continue to rise.²

The Martinez situation illustrates how serious negative outcomes may result from a lack of communication. All nurses, regardless of specialty, whether working for a private practitioner or large medical facility in any geographical region of the country, will face more and more future situations where they will have to deal with patients who are commonly termed limited English proficient or LEP. The importance that nurses have expertise in communicating with culturally diverse and LEP populations is stressed in the 14 Standards for Culturally and Linguistically Appropriate Services (CLAS), issued by the Office of Minority Health, Department of Health and Human Services. The following quotation, taken directly from the CLAS Standards, gives a strong rationale for the importance of effectively addressing language barriers in the healthcare setting:

"Accurate and effective communication between patients/consumers and clinicians is the most essential component of the healthcare encounter… When language barriers exist, relying on staff who are not fully bilingual or lack interpreter training frequently leads to misunderstanding, dissatisfaction, omission of vital information, misdiagnoses, inappropriate treatment, and lack of compliance. It is insufficient for healthcare organizations to use any apparently bilingual person for delivering language services — they must assess and ensure the training and competency of individuals who deliver such services."¹

Nurses need to understand why it is necessary to enhance their ability to communicate effectively with patients with LEP to ensure the quality of care and to comply with government regulations. They need practical strategies for improving direct communication with these patients. They also need to know how to use interpreters and how to evaluate who is appropriate to use as an interpreter.

The importance of language

Language is a key aspect of culture because it reflects what is important to members of a given culture, their patterns of thinking, and how they classify or describe a sequence of events or conditions. English, for example, is a language in which thinking occurs in a linear way. Time markers are used to describe conditions or give instructions, such as "first you do this, then you take that," or "my symptoms began yesterday and worsened by evening." In other cultures, stories or events may be described by weaving in and out of a central theme or by starting from the conclusion or final events and working inward in a circular sequence toward the beginning of the event.³

Given how closely a person's thinking and understanding is tied to language, it is easy to understand how culturally competent communication with patients and families who have LEP is necessary for quality care. Communicating effectively with patients from diverse cultural backgrounds requires the use of special skills and attention. With the nudging of governmental and professional agencies, health facilities are now addressing these issues.

Government, legal, and professional attention to language-access issues

Governmental, legal, and professional groups are giving increasing attention to the needs of patients with LEP. Language access is not a new issue. Title VI, Section 601, of the Civil Rights Act of 1964, which states that "No person shall on the ground of race, color, or national origin, be excluded from participation, denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance," was further clarified in the Policy Guidance on Title VI of the Civil Rights Act of 1964 in April 2001.⁴ This policy guide describes in detail the rights of people with LEP to meaningful access to federally funded health and human services. It specifically states that all "recipients of Federal financial assistance, such as grants, contracts, and subcontracts … provide the language assistance necessary to ensure such access, at no cost to the LEP person."⁴

In December 2000, the Office of Minority Health published a set of Standards for Culturally and Linguistically Appropriate Services (CLAS Standards). Four of the 14 Standards are taken directly from aspects of Title VI that pertain to language access for patients with LEP. In its Quality Assessment Performance Improvement project (QAPI), the Center for Medicaid and Medicare Services (CMS) has also increased its requirements in this area. CMS is requiring managed-care organizations to improve their oral linguistic services or implement CLAS, including the four standards that focus on language access. Likewise, The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has recently published a 30-month study of Hospitals, Language, and Culture: A Snapshot of the Nation. This study, funded by the California Endowment, addresses the issues of language and culture that impact the quality and safety of patient care. Domain five of this study is related to language services.⁵ The findings indicate that the provision of adequate language services for patients of LEP is still a work in progress and made the following recommendations for the improvement of language services (Note: explanations and details have been omitted):

5-1. Hospitals should consider establishing written policies regarding the provision of language services.

5-2. Hospitals should implement policies that do not permit the use of family members, particularly minors, for interpreting during medical encounters, except in the case of emergency when no other option is available.

5-3. Hospitals should assess both English and target language proficiency and require or provide training on the practice of healthcare interpreting for all individuals used to interpret.

5-4. Hospitals should consider incorporating language service programs into their safety and quality efforts by using process improvement structures and tools.

5-5. Policymakers need to initiate a national dialogue respecting a national certification program for interpreters in health care.

5-6. The impact of different forms of healthcare interpretation on healthcare quality and patient safety need to be quantified.⁵

At this point JCAHO expects nurses to determine from their comprehensive initial assessment the patient’s ability to understand and communicate in English. If the patient is found to be limited in English proficiency, this problem and the strategies for resolution are integrated into the patient’s nursing care plan. JCAHO views a patient’s inability to understand and speak English as a barrier to reaching their healthcare goals.⁶

Language requirements for nurses

All providers should assess the language needs of the populations they serve to determine the languages likely to be encountered. They need to identify the points of contact where language assistance is needed as well as the resources that are needed to provide it. Healthcare facilities are required to provide competent language assistance to patients in a timely manner. Bilingual staffs, staff interpreters, outside interpreter services (previously contracted for), volunteer community interpreters (through formal arrangement), and/or telephone services may be used. In accordance with the recommendations stated above, providers must not require, suggest, or encourage LEP persons to use friends, family members, or minor children as interpreters. An interpreter’s competency in English and in the patient’s language should be ascertained in advance. Competency includes demonstrated verbal proficiency in both languages, including a fundamental knowledge in both languages of any specialized terms or concepts, cultural sensitivity, and training in the skills and ethics of interpreting.

Knowledge of these regulations is an important protection to nurses — both those who are monolingual in English, and those who speak an additional language. Nurses should find out from their supervisor or the person in charge of patient services exactly what provisions have been made for patients who are LEP. Are staff interpreters available? If so, for which languages? Does the hospital or practice have a contract with an outside interpreter service to provide interpreters for languages not provided by staff interpreters? Is this a "face-to-face" interpreter service, or is it a telephone or other electronic service? How should the services be contacted? For what languages do they supply interpreters? What are the exact steps a nurse should take when encountering a patient who requires the assistance of an interpreter?

It is important to distinguish between the work performed by an interpreter and a translator. Though both transform words and meaning from one language to another, translators work with written language, and interpreters work with oral language. It is the job of both, however, to focus on the speaker’s or writer’s intended meaning rather than merely word-by-word meaning. This is one of the primary reasons why it is necessary to use trained interpreters. They have been trained to understand and interpret one linguistic code, with its geographical, cultural, and sociopolitical characteristics, into another. Often, this transformation from one language to another requires the use of very different words and expressions from the language spoken by one communicator to the language spoken by the other.

Nurses who are bilingual, or who speak another language to some degree, should be careful of being pressed into service as an interpreter if they have any doubts at all about their proficiency or knowledge of medical terms in either language. They should request training in interpreting skills before agreeing to interpret for patients. A nurse who tries to do a good deed by interpreting for a patient may end up being responsible for miscommunications that may result in the patient’s misunderstanding of the condition or treatment or the physician’s failure to comprehend the symptoms correctly, thereby making an incorrect diagnosis. Either situation could lead to a negative outcome and possibly a malpractice suit, which may name the nurse-interpreter as having caused the miscommunication.

In a recently published study, a research team audiotaped and transcribed 13 encounters in a hospital pediatric clinic in which Spanish interpreters were used. The team analyzed transcripts for errors in interpretation. They then categorized each error and determined whether or not the errors had a potential clinical consequence. Findings revealed many interpreter errors, the most common involving omission, followed by false fluency, substitution, editorialization, and addition. Many errors had potential clinical consequences — for example, omitting questions about drug allergies or omitting instructions on the dose, frequency, and duration of medications. Nonprofessional interpreters, such as family members (a child in one case), nurses, and social workers, made significantly more errors than professional interpreters. This study emphasized the importance of using trained interpreters for LEP patients.⁷

When nurses encounter patients who are accompanied by friends or family members acting as interpreters, it is important that nurses initiate a discussion about how communication will occur. Ask patients through the "interpreter," whether or not they have been told that a professional interpreter is available free of charge. A friend or relative may inhibit the patient from being open and honest. The patient may not want to disclose a personal issue in front of them. In some situations, it is possible that the person accompanying the patient is an abuser. With these issues in mind, ask patients whether or not they would like an interpreter.

If patients say they have been informed about interpreter services but decline assistance because of the presence of a friend or relative, explain that, in spite of the willingness of the person to help, errors that might affect the accuracy of the diagnosis or the understanding of the treatment plan may occur. These errors may occur due to lack of knowledge of medical vocabulary or failure to understand the role of the interpreter. Explain that should the patient desire it, the friend or relative can stay to "assist" the professional medical interpreter. Although a nurse cannot force a patient to use a professional interpreter, if it is determined that one would be necessary or beneficial to the quality of care provided, the nurse may wish to try to persuade the patient to reconsider the benefits of a medical interpreter. Be sure to record refusal to use an interpreter on the patient’s chart.

Never assume that patients who bring someone to serve as an interpreter do not understand English. These patients may have a fairly good comprehension of English, but lack the confidence or ability to speak it. Because they are fearful or embarrassed that they might misinterpret what someone tells them, they may bring someone with them, who they believe has a better knowledge of English than they do, along to interpret. Many of these so-called interpreters know no better English than the patient. In these instances, it may be preferable to carefully communicate with the patient by using simple English. Strategies for direct communication are outlined below.

Other dangers using family or friends as interpreters

Cultural issues may become major deterrents to accuracy of communication between nurse and patient when family members, friends, or even untrained bilingual staff members are used as interpreters. In many cultures, the roles and relationships between generations and genders are extremely structured and defined. There may be strong taboos against discussing, or even mentioning, sexual organs or functions to members of the opposite sex or to children. Patients may avoid discussing symptoms or problems that they perceive as being in any way sexual in nature.

The child or person interpreting may also feel that it is necessary to "revise" or omit any questions the nurse may ask if it is about a subject considered taboo by that culture or considered insulting or embarrassing to the patient. Even when the question does not concern a sexual organ or function, family/kinship roles may cause untrained family interpreters to omit or change information that they feel is somehow insulting or inappropriate. In addition, cultural beliefs or superstitions may cause untrained interpreters to modify or omit what the caregiver has said. For example, in Navajo traditional culture, it is believed the word precipitates the deed. In other words, discussing the possibility of a negative outcome is believed to bring that outcome about. Therefore, if a nurse or physician mentions the possibility of complications accompanying surgery, a well-meaning nonprofessional interpreter might omit mentioning this during interpretation. When children serve as interpreters, they are, in a sense, usurping the parental role of guide or decision-maker. This may cause major rifts in the family structure, which cannot be repaired even if the parent’s health is restored.

Never use untrained, untested staff as interpreters

Inaccuracies in both English and the language of the patient frequently occur when untrained and untested members of staff serve as interpreters. Imagine that you have a child who is between the ages of 8 and 14. Suppose that you had a serious illness and that because of a lack of a common language or an inability to speak, you had to have that child serve as an intermediary between you and a nurse or physician. How well versed in the vocabulary of your illness do you think that child would be? Do you think that child would have the knowledge, life experience, or vocabulary to both describe your symptoms to your caregiver and describe his or her diagnosis to you accurately enough for you to make an informed decision?

Often, so-called "bilingual" staff members are persons who immigrated to the U.S. when they were children. Though they may have stayed fluent enough to carry on every day functions in their native language, the forms and vocabulary they use have often become fossilized in the language of their development and education at that time of their arrival in the U.S., especially when English becomes their primary language. Often when the native language is spoken only with relatives at home, it doesn’t go beyond everyday conversational issues. On the other hand, those who may have immigrated to the U.S. and learned English as adults, may have managed to become fluent in every day spoken English but, unless they are clinicians, may lack the English language skills to describe either symptoms or procedures for care.

Another danger in using untrained staff as interpreters — especially those who serve in untrained positions, such as housekeeping employees — is related to class and status. Again, these social roles are much more rigidly defined in many other cultures. It would be extremely awkward, for example, for a "highborn" Russian émigré who was a lawyer in his country to describe prostate symptoms to a Russian-born housekeeping staff member from the "peasant class."

Finally, there is the matter of assimilation. Anthropologists and sociologists have broken assimilation into various stages; two of these stages are pertinent here. In one of these two stages, the person assimilating to a new culture rejects and criticizes that new culture. In the effort to "stay connected" to persons of his or her native culture, the person may unduly criticize that culture to the patient — including its medical beliefs and practices being used. An untrained staff interpreter in this stage of assimilation may knowingly or unknowingly cause the patient to mistrust the caregivers. Interpreters at this stage of assimilation could discount the nurse’s advice or instructions and interject their own opinions. For instance, the interpreter may suggest the patient ignore the nurse's instructions and recommend seeking traditional healing practices instead.

In the other stage of assimilation that applies here, the person totally rejects his or her native culture and those who belong to it. An interpreter in this stage may inadvertently ignore or disparage the patient’s cultural issues when they need to be carefully explained to the caregiver without bias. For example, the interpreter may not disclose to the nurse that the patient is taking herbal remedies when the patient is offering to share this information with the nurse.

Contacting a medical interpreter

Regulatory bodies, such as CMS, the Office of Minority Health, and JCAHO, are encouraging healthcare organizations to ensure that hospitals and practices gather information about every patient’s race, religion, and preferred language on standard admissions forms and patient information sheets. This information will alert the intake person if there is a need for an interpreter before the patient sees a nurse or physician. It should be this person’s responsibility to arrange for either a face-to-face interpreter or a telephone interpreter, if one is needed. If this does not happen and the nurse is faced with the need to assess or communicate with a patient who is LEP, the nurse should know, in advance, the services that are available through the clinical facility.

Strategies for improving direct communication with LEP patients

If an interpreter is not immediately available, or it is believed that the patient has a very basic knowledge of English, the nurse may greatly improve direct communication with the patient by following the procedures outlined below.^8,9

Speak slowly, not loudly. Remember that the patient is hard of understanding, not hearing. A loud voice implies anger; and in most cultures, the healthcare provider holds a very high position of respect and authority. When patients feel that the caregiver is angry, they tend to become anxious or feel intimidated and begin to answer questions in the way that they think will please the caregiver, rather than give the true picture of their complaint. The quality of the nurse-patient relationship cannot be overemphasized. When the relationship is a trusting one, the patient will feel more comfortable in sharing concerns. A trusting relationship is vital in any culture.

Face the patient and make extensive use of gestures, pictures, and facial expressions. By the same token, watch the patient's face, eyes, and other nonverbal communications carefully. When these don't agree with the patient's words, or if the patient's eyes or facial expressions are not congruent with what has been said, double-check carefully. But make sure not to assume that nonverbal communication used in your culture will be the same as the patient's. For example, eye contact is culturally determined. In many cultures, direct eye contact with an authority figure is considered disrespectful.

Avoid difficult and uncommon words and idiomatic expressions. Idioms are phrases or expressions that are based on culture rather than the sum of the meanings of each individual word. American English is fraught with idioms, such as "right on target," "in the nick of time," or "kill two birds with one stone." Americans use idioms to demonstrate friendliness, respect, or equality, too. While most idioms are perfectly simple and comprehensible — even to the youngest American-born patient, they tend to confuse, intimidate, and alienate most immigrants.

Don't complicate communication with unnecessary words or information. More is not better. Keep what you say simple. Strip the information you give down to bare essentials. Remember, also, that not all patients expect or want all the facts about their illness and care explained in full or want to know the truth about the prognosis for recovery. In many other cultures, a poor prognosis is not only hidden from the patient, but often the family, too. When ethical problems arise in this area, they need to be discussed by the treatment team, preferably including someone from the patient’s cultural background.

Organize what you say for easy access. Use short, simple sentences, starting with the subject, followed, as closely as possible, with the verb and a simple object. A good rule of thumb is that people tend to remember information in an inverted bell curve — what is said at the beginning and end is remembered best, while the information in the middle is missed or quickly forgotten. Put your information where it counts.

Rephrase and summarize often. Summarize what you understand the patient is saying, and check with the patient to see if your understanding is correct. When giving information or asking questions, try to say the same thing or ask the same question in at least two or three different ways.

Don’t ask questions that can be answered by "Yes" or "No." The patient’s answer will only tell you whether or not the question has been heard — not whether it has been understood. If you phrase questions in a way that requires the patient to respond with information (i.e., by beginning them with what, where, when, why, or how), they can only reply sensibly if they have understood the question. Ask a question that requires information rather than just a yes or no. A phrase like, "Tell me more about …" is a better approach.

Check the concept behind the word. The patient may interpret even the simplest instructions, such as "Keep the baby warm," "Wash the wound regularly," or "Eat a balanced diet" in a radically different way than that which you intended. Words only function as a means of calling up ideas and concepts gained through previous experience. When dealing with people who come from a different culture and lifestyle, it is important to remember that though the person may have learned the English words for something, they are probably associating it with experiences more closely tied to their cultural experience than to ours. For example, in the U.S., a "balanced diet" refers to a wide selection of foods, including vegetables, fruits, grains, dairy products, and proteins. In many other cultures, a balanced diet refers to combining "hot" and "cold" foods. Hot and cold do not refer to food temperature, but to type or quality of foods. Food classified as hot in one culture may be cold in another, so it is difficult to compile a list. In these cultures, a "balanced diet" is planned according to the seasons and/or a person’s state of health.

Don’t burden patients with decisions they are not prepared to make. Unlike most American patients, who wish to be given all options so that they can make an informed choice for themselves, people from most other cultures tend to believe in the "mystique" of the physician and the "healer's art." The physician is expected to review the case and tell them what to do. Asking the patient may compromise the faith in knowledge and expertise of the physician and the medical institution. Similarly, the nurse may be viewed as someone who should do the job without discussing too many options with the patient. It’s important to be sensitive to how much the patient wants to be involved in decision-making.

Learn a little of the language of the "majority" ethnic population you serve. Being able to engage in some small talk in the patient’s language indicates that you are interested in and care about the patient’s background and helps put the patient at ease. Recognize, however, that speaking a few words in the patient’s language does not necessarily make you a bicultural expert. Use the interpreter to bridge the cultural and language gap in clinical situations.

Using interpreters efficiently and effectively

It seems strange to speak to anyone, especially to a patient, through a third party, but this three-way communication can be made much more effective if the nurse learns to view the interpreter as merely a vehicle of communication between patient and nurse. The nurse should try to establish eye contact with the patient and talk to the patient rather than to the interpreter. This means that the nurse should not talk to the interpreter, saying, "Ask him or her if …," but use the second person, "you" stating, "Do you …" or "Have you experienced …" Watch the face and nonverbal communication  of the patient, not the interpreter.

The interpreter, nurse, and patient should ideally be in the form of a triangle where everyone sees each other. There may be cultural gestures or "looks" that may need to be interpreted. This triangular arrangement works well in clinical situations, but changes somewhat in other situations. Some behavioral health clinicians prefer that the interpreter stay out of sight of the patient because they want the patient to develop a primary relationship with the clinician, not the interpreter.

Below are some other strategies for using interpreters effectively.^5,6

When possible, use interpreters who are similar in age and of the same gender as the patient. In many cultures, it is inappropriate to share personal or health-related information with someone much younger or with someone of the opposite gender. As a rule, avoid using children as interpreters.

Brief the interpreter. Before talking with the patient, summarize for the interpreter what you will say to the patient, emphasizing the key information you wish to impart.

Explain information and ask questions in two or three different ways. During the actual discussion with the patient, don’t be afraid of repeating yourself. Try to choose different words and expressions with each explanation or question. This will help eliminate misunderstanding.

Avoid long or complicated sentences. Be concise and try to avoid superfluous words or ideas.

Keep it short. Don’t talk for more than one or two minutes without stopping to allow the interpreter to explain what you have said to the patient. It is important to stay focused on the points to be made. In busy clinical settings, the interpreter must be able to finish the interpretation and move on to the next patient.

Allow the interpreter "thought time." A professionally trained interpreter will try to capture the essence of what you mean rather than simply translate word-for-word. Sometimes it takes a bit of time to convey the same meaning in a language with an entirely different structure and communication pattern.

Don’t interrupt. Interrupting the interpreter while he or she is talking to the patient may cause him or her to “lose face” in the patient’s eyes, to lose the trend of thought, or even to forget some vital information

Don’t be impatient. Permit the interpreter to use as much time as is necessary to clarify a point.

Allow for the "directness of English." In the US, and especially in clinical situations, we tend to communicate using a very direct, succinct style. This directness may not work in other cultures. Don’t be concerned if the interpreter takes five to 10 minutes to summarize what you have said in two minutes. Likewise, don’t be concerned if the patient talks for five to 10 minutes and the interpreter tells you what has been said in two minutes.

Observe and respond to gestures and facial expressions. Position yourself so that you, the patient, and the interpreter are visible to one another. Use lots of gestures and facial expressions when you speak through the interpreter. Watch the patient’s eyes and facial expression — both when you speak and when the interpreter speaks. Look for signs of comprehension, confusion, agreement, and disagreement.

Remember that "culture" may even cause a professional interpreter to modify what you or what the patient has said. Clarify with the interpreter whether it is generally okay in the patient’s culture to discuss sexual or other "delicate issues" or give bad news to the patient. Ask the interpreter the best way to broach these subjects with the patient or family. Remember, however, that though the patient and interpreter may share the same language, they may be from different cultures. For example, there is great variation among groups who speak Spanish. It is always a good idea for nurses to learn something about the cultures and the "do's" and taboos of the primary social groups they serve.

In summary, no matter what cultural heritage patients come from, a trusting nurse-patient relationship is vital to establishing communication. Take just those few extra moments to show warmth and respect. Address patients by their formal name, unless they indicate otherwise. Be tactful and considerate. By developing knowledge and competence in communicating more effectively with patients who have LEP, the outcomes of patient care will be vastly improved. You are encouraged to dialogue with fellow staff members about specific ways your clinical unit can work more effectively with patients with LEP.