In 2013, nearly 62 million U.S. residents — 21% of the population — spoke a language other than English in the home, according to the U.S. Census Bureau. Statistics like these are raising questions in the healthcare arena about patient safety for millions of residents nationwide, who have limited English proficiency, when they seek care.
According to an article published in 2014 in the International Journal of Healthcare Quality, unaddressed language barriers can lead to low quality, unsafe and costly healthcare. When compared to English-speaking counterparts, LEP patients have a greater risk of line infections, surgical infections, falls, pressure ulcers and surgical delays, according to studies referenced in the article. They also have a greater chance of readmissions for certain chronic conditions due to difficulties with understanding how to manage their condition and take their medications.
Nurses like Lauren Micale, BSN, RN, CPHON, a bone marrow transplant coordinator at Nemours/Alfred I. DuPont Hospital for Children in Delaware, can attest to the importance of speaking a patient’s language. A few months ago, Micale was talking to a mother about her son, who had recently had a bone marrow transplant. During their conversation, the mother mentioned she had seen some blood in the child’s stool. She had not told anyone else because of the language barrier — and she did not realize it was important. Micale knew this could be a sign of skin breakdown and infections can be life threatening for these patients. She alerted the team and they addressed the problem.
Micale had started taking Spanish in grade school and fell in love with the language. In high school, she volunteered at a school with Spanish-speaking children and became aware of the significant need for accurate, in-person translation. Micale sought out a nursing school where she could minor in Spanish, and after much searching she finally found one. Most schools told her she would need to take summer classes or would be in school for an extra year in order to minor in Spanish, but the University of Delaware allowed her to finish on time and participate in a study abroad program in Ecuador.
“As a nurse who speaks Spanish, I can explain to patients and families what I am doing,” Micale said. “I’m also able to build trust and advocate for them with the team.”
Unlike Micale, Ida Bradley, BSN, RN, a member of the Navajo Tribe, had not planned to use her bilingual skills in nursing, but once she realized the value to patients, she dedicated her career to serving fellow Native Americans. Bradley had worked as a nurse for more than 11 years before she took her first job at the Northern Navajo Medical Center in Shiprock, N.M.
“I grew up in a traditional Native American home, and although I never met my grandmother, I was told she was a medicine woman,” Bradley said. “I knew about the values and teaching of our culture, and I could understand where my patients were coming from.”
The Northern Navajo Medical Center is one of eight facilities that serves patients who live in the Navajo Nation, which has a population of about 200,000 people and covers the corners of Arizona, New Mexico and Utah. The majority of patients who are fluent in Navajo — and not in English — are elderly, Bradley said.
The Navajo language is very descriptive, and she often uses visual pictures and analogies to explain health conditions to elderly patients. For instance, she sees patients who are suffering from pulmonary fibrosis after years of working in uranium mines and uses the image of a tree to help them understand the condition. The main tree trunk is the trachea, the branches are the bronchi, and the leaves are the alveoli. “In their mind’s eye, this gives them an idea of what their pulmonary makeup is like,” Bradley said.
She also sees patients who have been diagnosed with cancer and explains the purpose of an advance directive. Bradley also can explain to the healthcare team patients’ desire to go home before initiating treatment.
When they go home, patients typically seek out a “hand trembler” who will use rituals to diagnose the condition and tell them what type of healing ceremony is needed. Then the patient will find a shaman who can perform that specific ceremony, Bradley said.
“Doctors are sometimes surprised by this,” she said. “I can explain why they want to try traditional medicine and participate in ceremonies.”
Paula Schipiour, MSN, RN, associate director of the Chicago Bilingual Nurse Consortium, is working to bridge the language barrier gap in healthcare. The nonprofit organization helps internationally educated nurses obtain their nursing licenses in the U.S. The majority of the nurses who join the consortium speak Spanish, but there are others who speak languages such as Polish, Chinese, Serbian, Persian, Filipino and Korean.
“There is an incredible demand for nurses who are bilingual,” Schipiour said. “Here in the Chicago area we get calls from many hospitals that are looking to fill positions with nurses who can communicate with patients who aren’t proficient in English.”
The consortium helps foreign-born nurses move through the process of becoming licensed, which includes classes to help them become proficient in English and prepare for the NCLEX exam. The organization, which was founded in 2002, has helped more than 700 nurses representing 60 countries earn RN licensure in the U.S.
These nurses understand the financial and cultural challenges that come with moving to a new country, which allows them to better relate to their patients. They also notice the nonverbal cues and subtle signs that a phone or iPad translator may not be able to pick up, said Schipiour.
“It is highly preferable to have a caregiver who understands the patient’s language,” she said. “When people have multiple questions or are afraid to ask questions, they are much more willing to talk to someone who understands. It’s a safety issue.”
This safety issue was highlighted in a study published in 2007 in the International Journal for Quality in Health Care. The data showed that 49% of LEP patients who had adverse events experienced physical harm (any impact on their physiological or mechanical health as a result of healthcare error or systems failure), compared with only 29% of English-speaking patients.
The Bilingual Nursing Fellowship Program at South Mountain Community College in Arizona is using another approach to add bilingual nurses to the workforce. The program supports bilingual students fluent in Spanish who are at risk of dropping out of nursing school.
“Many students do not have the support to manage school, family and work,” said Loida Gutierrez, coordinator of the program. “We make sure students have academic support by providing qualified tutors, keeping track of their progress in classes and pairing them with a mentor who is an RN.”
Roughly 50 students are in a cohort, and they can take classes together. “We find that students who are in a cohort rather than on their own have a higher chance of finishing nursing school,” Gutierrez said. “The support they receive encourages them, and in some cases has been the determining factor in their decision to finish school.”
According to the U.S. Census Bureau, more than 38 million people speak Spanish in the U.S. — the most common language other than English by far. The second and third most common languages are Chinese with 3 million people and Tagalog with 1.6 million. Kathlene Wilson, a nurse recruiter, sees the preponderance of Spanish speakers reflected in the staffing needs of hospitals.
“Certain parts of Florida, Texas and Arizona look for bilingual nurses who speak Spanish,” said Wilson, president of Wilson Staffing Network based in Houston. “The need is not just in hospitals, but also in places like community clinics and blood donation centers where translation services are not available.”
The minority population is projected to rise to 50% of the total population by 2060 — compared with roughly 40% now, according to the U.S. Census Bureau. Nurses like Schipiour say these statistics bode well today and in the future for members of the profession who are fluent in two languages.
“I had a nurse from Chile who spoke Spanish fluently and moved to Tennessee,” she said. “She applied for three positions and was accepted for all three. Employers seem to jump at the opportunity to hire these bilingual RNs.”
Heather Stringer, a freelance writer, contributed to the writing and research of this article.
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