About Cultural Competency in Nevada (342)Page 15 of 18

14. Communication Tools

Data from the U.S. Census reveal a high degree of linguistic diversity, with more than 59 million residents speaking a language other than English at home. More than 25 million people live in linguistic isolation, a termed coined by the U.S. Census Bureau, in which no one in a household over 14 years of age speaks English at least very well (NCCC, Nd).

In Nevada, nearly 25% of residents speak a language other than English. The largest non-English language spoken is Spanish, representing 20% of Nevada’s population. The next most-common non-English language is Tagalog (3%), followed by Chinese (Mandarin, Cantonese, 1.1%). As a comparison, New York City—with a population of over 8 million people—has more than 800 spoken languages (Data USA, 2023).

On August 11, 2000, the President signed Executive Order 13166, “Improving Access to Services for Persons with Limited English Proficiency.” The Executive Order requires Federal agencies to examine the services they provide, identify the need for services for those with limited English proficiency, and develop and implement a system to provide meaningful access to those services for people with limited English proficiency (NIH, 2022, August 31).

14.1 Good Communication

The intimate and sometimes overwhelming nature of health concerns can make communication challenging. Nevertheless, patient-centered communication is fundamental to ensuring good health outcomes, reflecting long-held values that care must be individualized and responsive to patient health concerns (Kwame and Petrucka, 2021).

Effective communication is a two-way dialogue between patients and care providers. In that dialogue, both parties speak and are listened to without interrupting; they ask questions for clarity, express their opinions, exchange information, and grasp entirely and understand what the others mean (Kwame and Petrucka, 2021).

Cultural competence has been linked to increased patient satisfaction and treatment adherence. By contrast, cultural and linguistic differences between healthcare providers and patients can cause significant miscommunication, decreasing patient trust and satisfaction (Jongen et al., 2018).

If a provider lacks cross-cultural communication skills or if interpretation and translation services are not provided, the impact on a patient can be dire. Poor communication contributes to an incomplete and inaccurate health history, misdiagnoses, and the failure of a patient to understand their health condition and recommended treatment. This can lead to misuse of medications, repeat visits, and lack of informed consent (NCCC, nd).

Effective communication means providing information to an individual in an understandable and accessible way. The goal is to increase knowledge about prevention and maintenance of good health while positively influencing health behaviors and attitudes. This involves verbal, written, and nonverbal communication (HHS, 2022).

Studies have shown that a consistent communication-related barrier in nurse-patient interactions is miscommunication, which often leads to misunderstandings between nurses, patients, and their families. Additional communication-related barriers include language differences, poor communication skills, and a patient’s inability to communicate due to their health state—especially in ICU—dementia, or end-of-life care contexts (Kwame and Petrucka, 2021).

14.2 Working with Interpreters

Federal law requires healthcare providers who receive federal funding to offer interpretation services to patients with limited English proficiency. Using interpreters and translation services reduces disparities by bridging the communication gap between providers and patients with limited English proficiency. These services ensure that all parties understand a provider’s medical instructions and diagnoses and can also provide a more comfortable and trusting environment for patients.

Healthcare organizations should not use family members, children, other patients or visitors, or untrained staff as interpreters. Interpreters are communication professionals who will interpret everything that is said, maintain confidentiality, and provide a cultural context.

Healthcare providers are responsible for the actions of interpreters and translators, ensuring that they act ethically, which may not always be easy to implement. Interpreters and translators are required to show respect for all involved, respect confidentiality, interpret accurately, convey cultural information, and remain impartial (Louw, 2016).

Working with Interpreters [4:57]

Source: Legal Services New Jersey.

Test Your Knowledge

Question 1: If a person asks for an interpreter, can I assume they won’t understand if I say something to a colleague in front of the patient?

Answer: It is not uncommon that a person who asks for an interpreter understands English quite well. Any comments you make to other providers or to the interpreter might be understood by the patient.

Question 2: Today, I had a patient who I thought might need translation assistance, but the patient declined this service. I didn’t want to embarrass her by insisting—I assumed her refusal meant she would clearly understand everything we were going to discuss—so, I just dropped it.

Answer: If a patient refuses language assistance services, ask them to sign a form that says they understand that language assistance is available, and have chosen to decline these services. The form must be available and signed in the patient’s native language or completed orally if he or she is unable to read in their native language.

Document that the individual was notified about these rights and include the patient’s preferences for utilizing language services in the future. Written documentation is needed to communicate with other providers and to indicate that language services are available and were offered.

Modified from Think Cultural Health: Working Effectively with an Interpreter

Example Case: Mr. Louis and His Granddaughter

Mr. Louis just celebrated his 70th birthday with his family and neighbors with lots of good food, music, and dancing. Mr. Louis kept everyone up late, telling stories about his childhood in Haiti. Mr. Louis was grateful to have so many loved ones close by, but he still misses Haiti after moving so many years ago.

Soon after his birthday, Mr. Louis visited his physician for a checkup. His physician sent him for additional testing, which showed the presence of prostate cancer. Let’s see what happens during Mr. Louis’ appointment with the oncologist, Dr. Emily Parker.

The Initial Appointment
Mr. Louis brought his granddaughter, Esther, to his oncology appointment at the hospital to help him speak with the oncologist. He knows some English, but he was worried that he would not understand everything that the doctor might say. Plus, Mr. Louis was nervous, he wanted his granddaughter there for support.

Once the appointment began, Dr. Parker and Esther did all the talking. Mr. Louis did not get a chance to speak, and he did not understand most of what Dr. Parker and Esther were saying. After a few minutes, Esther seemed to be arguing with Dr. Parker. This embarrassed Mr. Louis, and he stayed quiet.

After the First Appointment
After the appointment, Esther explained to her grandfather in French that, to treat his cancer, he would undergo a procedure the next week that would implant radioactive seeds. Esther told Mr. Louis that the procedure was simple, painless, and without side effects. She did not mention what else the doctor said or what she seemed they seemed to be arguing about during the visit.

Back at home, Mr. Louis began to worry about the procedure. He researched the procedure online and talked with his friends. He learned that the procedure did have side effects, including the possibility of incontinence. Remembering how Esther had argued with the doctor, Mr. Louis wondered if she had told him the truth about her conversation with Dr. Parker.

The Surgical Appointment
The next week, Mr. Louis and Esther arrived at the admissions office at the hospital. “No surgery,” said Mr. Louis firmly. The admissions clerk looked up in surprise, and Esther quickly started talking to her in English. She explained that Mr. Louis did not really understand the issue and that he really did want the surgery.

Esther asked to sign the papers for her grandfather, but the admissions clerk explained that without legal standing, Esther was not eligible to do so. Mr. Louis continued to quietly say, “No surgery.” The admissions clerk had no idea what to do. The surgical staff called to say that they were waiting for Mr. Louis. Esther glared at her grandfather.

The clerk spent almost half an hour trying to find a hospital staff member who spoke French, but no one was available. The surgery staff called again, saying that if Mr. Louis did not arrive shortly, they would have to reschedule his procedure.

Exasperated, Esther insisted that Mr. Louis undergo the procedure. She said, “The hospital has people ready to do this. All those people's time will just be wasted. Come on, just sign the paper and we can get you upstairs.” Mr. Louis said again, “No surgery.” Esther had no choice but to take him home.

Mr. Louis’s Response
“I depended on my granddaughter to help me with my oncology appointment. But she did not tell me the truth about the surgery and my options to treat my illness. I am really angry that I came very close to having a surgery I did not want! It was so frustrating to not be able to communicate directly with my doctor. All I wanted was someone who could listen to me and explain my options.”

Mr. Louis’s Doctor Responds
“These days, I see a lot of patients who don’t speak English very well or at all. I’m used to communicating with a family member or friend instead of the patient. In fact, I ask patients to bring someone who can interpret for them. It's so much easier that way!

But when I heard about Mr. Louis’ situation from our admissions clerk, I was shocked! I did not recommend the procedure that Esther scheduled for her grandfather. I actually suggested “watchful waiting” as Mr. Louis' treatment option. But, during the consultation, his granddaughter insisted that Mr. Louis undergo the procedure. Now that I think about it, I didn’t speak much with Mr. Louis since Esther seemed to be in charge. I thought I was doing the right thing by speaking with the family member that Mr. Louis brought with him. Now, knowing that Mr. Louis did not want surgery scares me. I wish I had been able to speak directly with Mr. Louis without his granddaughter interfering.”

Offering language assistance services, including a competent medical interpreter, helps patients with limited English proficiency understand and make informed decisions about their medical care. Unfortunately, Mr. Louis almost had a surgery that he did not want, and the surgery could have caused side effects about which he had not been informed. Operating on a patient who did not want surgery or who was not aware of potential adverse effects could have serious liability implications for the doctor and the hospital.

Also, the hospital had a surgery team and room sitting idle because a patient was scheduled for a procedure that he did not want. In this case, the cost of providing a trained interpreter would have been significantly less than the costs that the hospital incurred from this.

Think About It

  • How would you feel if this happened to you or a family member?
  • Could this happen at your organization?
  • Does your workplace offer communication assistance?

Source: HHS, 2022

14.3 Working with Traditional Medicine/Healers

American Indian and Indigenous peoples utilize traditional medicine/healing for health and well-being. Modern, Western-trained healthcare practitioners receive minimal training and education on traditional these healing practices and their application and integration into healthcare settings. Lack of knowledge and practice guidelines on how to navigate these two healthcare perspectives creates uncertainties in the treatment of American Indian and Indigenous peoples. Such conflicts can undermine patient autonomy and result in culturally incongruent practice (Esposito and Kahn-John, 2022).

One challenge Western-trained healthcare a provider may face is respecting a person’s autonomy by allowing them to choose and prioritize health and wellness interventions they feel best fit their physical, mental, emotional, and spiritual needs. These are valid concerns and must be considered, discussed, and explored to maintain optimal health and safety of patients (Esposito and Kahn-John, 2022).

For Western-trained healthcare providers, training in traditional medicine/healing and learning how to integrate Western medicine and traditional medicine is an important part of providing comprehensive, culturally inclusive, and effective care. Traditional medicine/healing education should be integrated on several levels of Western medical training (Esposito and Kahn-John, 2022).

14.4 Language Assistance Services

In the United States, healthcare organizations are required by law to provide interpretation services at no cost. Notification of communication and language assistance services allows organizations to avoid legal ramifications from miscommunications between provider and patient, which could potentially lead to malpractice and legal action against a provider and their organization.

Language assistance services such as oral interpretation, translation of written documents, signage, and wayfinding symbols greatly improve communication for patients with limited English proficiency and those who are deaf or hard of hearing. Healthcare organizations should notify patients that communication and language assistance services are available when scheduling an appointment. This helps patients (and their families) make better use of services and helps them become more informed consumers of healthcare (HHS, 2022).

UC Davis nursing students reducing language barriers to improve health care [3:19]

Source: Betty Irene Moore School of Nursing at UC Davis.

Providers might try to “get by” with the limited English skills of patients, their own inadequate foreign language skills, or unqualified interpreters, such as patients’ friends or family members or untrained staff. Examples of documented patient safety events due to a lack of language assistance include performing an x-ray on the wrong part of the body, falls due to the patient not knowing to ask for assistance, and inability to treat emergency room patients due to failure to obtain medical history or medication list (PSNET, 2019).

14.5 TeamSTEPPS

The TeamSTEPPS Limited English Proficiency program provides hospitals with the tools to develop and implement a plan to train interpreter and clinical staff in teamwork skills, specifically within the context of working with patients with limited English. The program includes train-the-trainer resources and instructional guides that include short case studies and videos (PSNET, 2019).

The success of TeamSTEPPS is well-documented and field testing concluded it was easy to implement and fostered staff learning. In addition to implementing the TeamSTEPPS program, hospitals are encouraged to: 1) foster a supportive culture for the safety of diverse patients, 2) adapt current systems to better identify medical errors among patients with limited English proficiency, 3) improve reporting of medical errors for patients with limited English proficiency, 4) routinely monitor patient safety for patients with limited English proficiency, and 5) address root causes to prevent medical errors among patients with limited English proficiency (PSNET, 2019).