Intercultural communication is communication between people with differing cultural identities. It can be complicated, messy, and at times contradictory. Intercultural relationships are formed between people with different cultural identities, including friends, romantic partners, family, and coworkers. Some of the benefits include increasing cultural knowledge, challenging previously held stereotypes, and learning new skills (Hollingsworth et al, 2021).

Intercultural communication allows us to step outside of our comfortable, usual frame of reference and see our culture through a different lens. As we become more self-aware, we may also begin to challenge our tendency to view our own culture as superior to other cultures (Hollingsworth et al, 2021).

In the U.S., there is 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, in which no one in a household over 14 years of age speaks English at least very well (NCCC, n.d.). For example, New York City—with a population of over 8 million people—has more than 800 spoken languages (Data USA, 2023).

In Washington State, 20% of residents speak a language at home other than English. The most common non-English language spoken is Spanish. Census data from 2021 indicated that nearly 9% of the households in Washington speak Spanish at home as the primary shared language between all members living in the household (Data USA, 2023).

Language assistance services such as oral interpretation, translation of written documents, signage, and wayfinding symbols improve communication for patients with limited English proficiency and those who are deaf or hard of hearing. This helps patients (and their families) make better use of services and also helps them become more informed consumers of healthcare (HHS, 2022).

Quality and cost drivers indicate that patients with limited English proficiency have longer hospital stays when professional interpreters were not used during admissions and discharge. There is also a greater risk of line infections, surgical infections, falls, and pressure ulcers due to longer hospital stays compared to English-speaking patients with the same clinical condition (AHRQ, 2020).

Patients with limited English proficiency have a greater risk of surgical delays and readmission due to greater difficulty understanding instructions, including how to prepare for a procedure, manage their condition, and take their medications, as well as which symptoms should prompt a return to care or when to follow up. There is also a greater chance of readmissions for certain chronic conditions among racial and ethnic minorities compared to their white counterparts (AHRQ, 2020).

These differences can also be caused by low literacy, or other communication barriers that make patients more likely to misunderstand discharge and medication instructions. With the advent of financial disincentives for excessive readmissions, greater attention should be paid to ensuring effective communication, including appropriate medication reconciliation, at discharge (AHRQ, 2020).

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). When communication works, information is provided in an understandable and accessible way. This should occur across verbal, written, and nonverbal communications (HHS, 2022). 

Poor intercultural communication skills or lack of translation services can impact patient care. It can contribute to incomplete and inaccurate health histories, misdiagnoses, and the failure of a patient to understand their health condition and recommended treatment (NCCC, n.d.).

Studies have shown that miscommunication often leads to misunderstandings between nurses, patients, and their families. Poor communication can contribute to a patient’s inability to communicate due to their health state, especially someone in ICU, a person with dementia, or a person nearing the end of life (Kwame and Petrucka, 2021).

4.1 Working with Interpreters

In the United States, healthcare organizations are required by law to provide interpretation services at no cost. These services reduce disparities by bridging the communication gap between providers and patients, especially patients with limited English proficiency.

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

Interpreters and translators differ in their jobs. A translator works with the written word, translating from one language to another while an interpreter translates spoken information.

Interpreters’ and translators’ roles are diverse and include being a cultural broker, patient advocate, co-therapist, team member, and institutional gate keeper. It is often the provider’s responsibility to train interpreters and translators working under their supervision in procedures and ethics (Louw, 2016).

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).

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 (AHRQ, 2023).

Parents often rely on their children to translate and interpret the new culture and language. It has been reported that such expectations and consequent obligations led to aggression, excessive risk-taking, and social problems in those children (Taylan and Weber, 2022).

The translation of doctor-patient interviews by non-professional translators can lead to an increase in the total amount of errors due to omitting or adding content when translating from the mother tongue into the official language. Relatives with higher levels of education made fewer errors, while those living with patients made significantly more errors by adding content (Taylan and Weber, 2022).

For non-professional interpreters, translation is often error-prone, especially when translating from their native language into the official language. In patient care, it is important to understand exactly what needs to be translated and the translation be effective and secure. In written communication, it is important to remember that not everyone can read or write their own spoken language. This is particularly important for declarations of consent. Visualizing this content with images and diagrams can be helpful when a person lacks written language skills (Taylan and Weber, 2022).

4.2 Cultural Brokers, Community Health Workers, and Traditional Medicine/Healers

Cultural brokers, community health workers, and traditional medicine/healers can be a vital tool for enhancing intercultural communication. These individuals are often familiar with community resources and cultural and religious issues that can affect a person’s approach to healthcare.

A cultural broker’s role can vary depending on patient and provider need, but they must be knowledgeable about the cultural group they serve. An individual acting as a cultural broker should be a trusted and respected member of the community but does not need to be healthcare professionals (AHRQ, 2023).

Community Health Workers (CHWs) play a critical role in the health of their communities, linking diverse and underserved populations to health and social service systems. Based on their life experience and role as health influencers within their communities, CHWs work to reduce social and racial disparities in healthcare. CHWs can improve health outcomes and the quality of care while achieving significant cost savings (WSDOH, 2024).

For Western-trained healthcare providers, learning about traditional medicine and healing practices and integrating these practices with Western medicine is an important part of providing comprehensive, culturally inclusive care (Esposito and Kahn-John, 2020).

American Indian and Indigenous peoples often practice traditional medicine and healing. Unfortunately, Western-trained healthcare providers receive minimal education on these traditional practices. Lack of knowledge and practice guidelines on how to navigate these two healthcare perspectives creates uncertainties for providers and patients. Such conflicts can lead to distrust and undermine quality of care for these communities (Esposito and Kahn-John, 2020).

4.3 Improving Intercultural Communication

Intercultural communication has become an increasingly important part of the healthcare environment. Increased migration means that healthcare is much more complex and diverse.

Research has clearly shown that communication between healthcare providers and migrant and ethnic minority patients tends to lead to worse outcomes compared to those between healthcare providers and patients belonging to the same majority groups. For instance, migrant and ethnic minority patients ask fewer questions, have a reduced understanding of their illness, are less adherent to treatment recommendations, and have higher rates of misdiagnoses compared to ethnic majority patients (Schouten et al., 2023).

To address these issues, healthcare providers need to be trained in basic verbal and nonverbal communication skills, situational and self-awareness, adaptability, and knowledge about cultural issues. Basic communication skills include showing empathy and respect, attentively listening, understanding the social and cultural aspects of a patient’s illness, and acknowledging patient preferences. Self-awareness means healthcare providers are aware of their own cultural identity, beliefs, and biases (Schouten et al., 2023).

4.3.1 National CLAS Standards

Culturally and Linguistically Appropriate Services (CLAS) standards are a set of standards intended to advance health equity, improve quality, and help eliminate healthcare disparities. CLAS provides a blueprint for individuals and healthcare organizations to implement culturally and linguistically appropriate services.

CLAS standards can improve the quality of services provided to all individuals, which will ultimately help reduce health disparities and improve health equity. The standards encourage respect and responsiveness: respect the whole individual and respond to the individual’s health needs and preferences.

To reduce barriers to accessing quality and appropriate care for priority populations and advance health equity, Washington’s Interagency Council on Health Disparities has prioritized the implementation of the CLAS Standards within healthcare organizations. Part of the Council’s work is to identify ways to help ensure people have access to culturally and linguistically appropriate health information and services.

This means all health services, including telemedicine services:

• Are culturally responsive.
• Provide meaningful access to language services.
• Are provided in an equitable and inclusive manner.

CLAS Standards training information is available here

4.3.2 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 (AHRQ, 2023).

The success of TeamSTEPPS is well-documented, easy to implement, and fosters staff learning. To implement the 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 (AHRQ, 2023).

Modified from Think Cultural Health: Working Effectively with an Interpreter