Multilingual Health Care

Navigating the elaborate health care system can be complicated enough, but for limited English proficient (LEP) patients, the challenges are especially difficult. According to an article published by The Joint Commission, approximately 20 percent of the U.S. population, about 57 million individuals, speak a language other than English at home, and approximately 25 million, or 8.6 percent of the U.S. population are defined as being LEP.

The inability to understand and communicate in English for these patients can lead to poor quality of care, decreased access to health care services, an increase in medical errors, poor compliance and poor health outcomes. Multiple studies have shown that when language interpretation services are lacking, patients are placed at additional risk for receiving care that does not align with their needs, and may lead to negative outcomes. The Joint Commission article points out that compared to English-speaking patients, LEP patients have:

  • Longer hospital stays when professional interpreters were not used at admissions.
  • Greater risk of line infections, surgical infections, falls, and pressure ulcers due to misunderstood post-care instructions.
  • Greater risk of surgical delays due to difficulty understanding instructions, including how to prepare for a procedure.
  • A greater chance of readmissions for certain chronic conditions due to difficulty understanding how to manage their conditions and take their medications, as well as which symptoms should prompt a return to care or when to follow up.

Of the 322 languages spoken in the U.S., Spanish is the second most common. According to the U.S. Department of Health and Human Services, Hispanics/Latinos make up 16.9 percent of the U.S. population, with 33 percent stating they are not fluent in English. The Pew Research Center expects this number to rise to 29 percent by 2050. This alone should be enough to make health care providers take notice.

What’s Been Done So Far?

Although it may seem that the simple answer is to ensure that an interpreter is available for LEP patients, interpreters who can deliver culturally and linguistically appropriate services in a medical setting have to be exceptional. The Standards for Culturally and Linguistically Appropriate Services in Health Care (National CLAS Standards) were created to set that high standard of care.

Originally published in 2000 by the Office of Minority Health (OMH) of the Department of Health and Human Services (HHS), they provided a framework for all health care organizations to best serve the country’s increasingly diverse communities. This ideally ensures that all populations are receiving comparable levels of care across the country. In the fall of 2010, the OMH launched the National CLAS Standards Enhancement Initiative to revise, clarify, and expand upon the standards. This includes 15 standards intended to be “the cornerstone for advancing health equity through culturally and linguistically appropriate services.” So far, seven states have passed mandates to increase cultural and linguistic competency for their health care workforce.

Are Interpreters the Answer?

Certainly, appropriately trained interpreters are a key component of meeting the standards. However, the fact that someone is proficient in both languages is not all that’s needed to ensure the quality of health care communications. In fact, as one study revealed, even bilingual nurses who have not been trained as medical interpreters may not provide the appropriate level of interpretation. In the findings, approximately 50 percent of the encounters “had serious miscommunication problems that affected either the physician’s understanding of the symptoms or the credibility of the patient’s concerns.” The study listed four processes that were affected by interpretations that led to misunderstandings.

  1. Physicians resisted re-conceptualizing the problem when contradictory information was mentioned.
  2. Nurses provided information congruent with clinical expectations but not congruent with patients’ comments.
  3. Nurses slanted the interpretations, reflecting unfavorably on patients and undermining patients’ credibility.
  4. Patients explained the symptoms using a cultural metaphor that was not compatible with Western clinical nosology.

In an effort to account for some of these translation errors, more attention has been paid to the ways translators are trained and certified. The National Council on Interpreting in Health Care (NCIHC) helps clarify the need for qualified interpreters and sets standards for their practice. It defines a qualified interpreter as “an individual who has been assessed for professional skills, demonstrates a high level of proficiency in at least two languages, and has the appropriate training and experience to interpret with skill and accuracy while adhering to the National Code of Ethics and Standards of Practice published by the National Council on Interpreting in Health Care.”

How Primary Care Providers Can Best Provide Multilingual Care

If you are struggling to provide the best multilingual care for your patients, a good place to start is with the National CLAS Standards and an assessment of how well your practice is aligning with them. In addition, the HHS provides a number of free online cultural competence trainings for health care providers, including physicians and nurses. In addition, consider integrating best practices and following the Professional Patient Advocate Institute’s tips for phone or video interpretation and certification recommendations when working with an interpreter. Finally, ask yourself a few key questions:

  1. Are you confident that you understand the needs of your LEP patients?
  2. What steps are you taking to ensure that interpreted interactions are accurate?
  3. Are you taking cultural factors into consideration when addressing language barriers?
  4. How are you ensuring that your LEP patients fully understand all information they are given?
  5. What indications do you have that “informed consent” from LEP patients is truly informed?
  6. How are you integrating cultural competence as an essential aspect of quality patient care?

Understanding the resources available to you and the ways you can evaluate your ability to provide multilingual care are among the best ways to help your patients achieve healthy outcomes.

There are certainly numerous challenges involved with ensuring that LEP patients are receiving the quality patient care that they deserve. Clear and reliable communication is a foundation for providing quality care for LEP patients. With the continued growth that is anticipated for this population in coming years, it’s essential that health care professionals integrate cultural competence and the needed resources to provide multilingual health care to their patients who need it.

Additional Resources