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Understand and overcome language, cultural barriers

Hospitalist Management Advisor, October 1, 2007

As the demographic of the country changes and the number of people who cannot speak English rises, overcoming language and cultural barriers has become an increasingly difficult problem for hospitalists who rely on effective communication with their patients.

As we discussed in last month’s Hospitalist Management Advisor, language barriers are not just frustrating for physicians and patients; recent studies show they can have a direct effect on patient care, including readmission rates (See “Take the reins on your program’s readmission rates,” September). But before you can effectively address the language barrier, you must understand the scope of the issue.

By the numbers

There are roughly 50 million people living in the United States today who speak a language other than English, and more than half come from Spanish-speaking countries, according to the latest U.S. census. The census also reveals that 14 million people have trouble speaking English.

Hospitalists may regularly find themselves on the frontlines of this issue because they are often the first ones to see, communicate with, and refer a patient to other specialists.

Alex Smith, MD, a hospitalist who specializes in palliative care at Brigham and Women’s Hospital in Boston, is researching ways to provide culturally congruent care. Smith says, for him, language is only the most superficial challenge in navigating these -relationships.

According to Smith, the largest numbers of nonEnglish-speaking patients at Brigham and Women’s Hospital are Haitian and Latino, as well as Chinese and Vietnamese.

“Fortunately, we have a fantastic interpreter services department that helps not only with interpretation of language, but of cultural beliefs, norms, and explanatory models of illness,” says Smith. “In the biomedical explanatory model, the sources of disease can be traced back to germs, genes, or the environment. In other cultures, the explanatory model of illness may be completely -different.”

He cites several Asian cultures as an example. “In many Asian cultures, illness is said to arise from an imbalance in energy or equilibrium,” he says. “In a faith-based model, illness may arise from beliefs, misdeeds, or spirits. In some explanatory models, humans use supernatural powers to cause illness, such as the evil eye. Without eliciting and understanding the patient’s explanatory model for illness, hospitalists may be frustrated by repeat admissions and nonadherence, and label patients ‘noncompliant.’ ”

Smith has seen this firsthand. “In one case, I had a Cambodian patient who believed that her shoulder injury was due in part to the trauma of losing a baby as she fled Cambodia during the rise of the Khmer,” he says. “In another, friends of a woman from the Azors believed her daughter’s severe degenerative neurological condition was caused by failure to use a folk remedy for a childhood ailment.”

Bridging the divide

Hablamos Juntos, an $18.5 million initiative funded by the Robert Wood Johnson Foundation based in Fresno, CA, is helping hospitalists bridge this cultural gap by developing different models for cultural and language competency. According to its reports, one in five Spanish-speaking patients has not pursued necessary care due to the language barrier. Spanish speakers in the United States constitute a ratio of more than one in 10 residents.

“We know that providers see helping Spanish-speaking patients benefit from the healthcare system as an important priority,” says Yolanda Partida, executive director of Hablamos Juntos. “Nearly seven in 10 [healthcare] providers, or 68%, see the issue as a top or important priority.”

According to Partida, some hospitalists say the primary barrier to doing more is the cost of building an infrastructure to accommodate these changes.

But as the potential liability for hospitals grows, the higher costs of mistakes made by using untrained interpreters, and the cost of poorer healthcare due to inadequate communication, must also be taken into -consideration.

Strategies to overcome barriers

The following are seven strategies hospitals and hospitalist programs can implement to deal with language and culture barriers.

1. Hire bilingual staff

Healthcare organizations often use family members and friends of the patient as interpreters, and that can present a series of problems. Such interpreters may lack the appropriate language skills and knowledge of medical terminology. Additionally, such communication compromises confidentiality, censors important information, and jeopardizes family dynamics, especially when children are used to interpret. According to Partida, studies show that the skills of trained interpreters go beyond an ability to speak a language, especially when technical concepts have no translation in their language.

Having a provider on staff who speaks the same language as his or her patients, especially if he or she is of a similar cultural background, can help your program accomplish the following:

Save time

Eliminate errors in communication

Aid proper and effective diagnosis and treatment

Recruiting for bilingual positions can be difficult, but Diversity RX (www.diversityrx.org), a comprehensive Web site that contains tools to address linguistic and cultural barriers, offers this suggestion: “Foreign-trained healthcare workers can be retrained and utilized in professional or paraprofessional roles. Special programs can assist them to become certified or licensed in their original profession, or can train them for other healthcare roles, such as physician assistant or community health worker.”

2. Use a professional interpreter service

Just over two years ago, the National Council for Interpreters in Healthcare developed national standards of practice for medical interpreters in order to define the characteristics and competencies of a qualified healthcare interpreter. (See www.ncihc.org for the full report.)

Healthcare organizations currently use a variety of approaches to obtain professional interpreter services.

For instance, a hospital can obtain interpreter services through an outside agency. Such an agency may specialize in medical interpreting or provide a spectrum of interpretation specialties. Alternatively, an organization with another set of services, such as an immigrant social service agency, may market an interpretation service. Use of an outside agency works well when your needs are intermittent and diverse, and your organization can also use an interpreter service to supplement your regular staff of interpreters.

Your organization can also employ telephone interpretation services—also known as remote consecutive interpretation—through outside agencies. Often, hospitals use these services for the following situations:

Emergencies, when it will take too long to get an interpreter in-person

Rare languages in which a local interpreter is not available

Simple communications (e.g., setting up appointments or giving lab results)

An interpreter should be physically present, however, for more complex communications where nonverbal cues are an important part of the communication and the accuracy of the interpretation is critical.

For a list of interpreter associations that focus on healthcare interpreting, go to www.ncihc.org/hciaus.aspx.

3. Use universal healthcare symbols

Hablamos Juntos is working to develop and test universal symbols for health signage that will be more effective at helping all patients navigate around hospitals, regardless of what language they speak. This information can include the following nonverbal cues:

Maps and signs

Overt clues in the architecture and interior design of a facility

Use of color, pattern, and texture

4. Standardize language assessment tests

Although native speakers are generally proficient in the target language, problems can arise. The dialect may be inappropriate, sociocultural differences may interfere, and medical terminology may be lacking depending on where the provider received medical training. Standardized evaluation tests of a provider’s linguistic skills and cultural awareness would help to address this issue, and help hospitalists identify the best person to call for each situation.

5. Offer interpreter skills training to volunteers

One cost-effective strategy, long popular with -hospitals, is to utilize employees who speak other languages as volunteer interpreters when needed. This strategy is particularly useful in emergency situations. However, without a formal evaluation of language skills, this approach can cause problems and, in some cases, even be dangerous. Few employees have received any training in medical interpreting skills, ethics, or vocabulary.

Diversity RX offers two examples of volunteer interpreters: “A hospital housekeeper, in the United States for two years, fluent in her native language but barely speaking English, may be called upon to interpret for a patient being prepared for surgery. Or an American-born nurse with two years of college French under her belt may be asked to interpret for a Creole-speaking Haitian refugee with a grade school education. In either situation, can we be sure that communication, let alone informed consent, has truly occurred?”

It is important to note that job conflicts may arise when these voluntary interpreters are called away from their regular duties and asked to fill gaps they were not originally hired for. Job responsibilities may not be met, and the interpreter may feel uncomfortable and ill-prepared for the situation he or she is put in.

6. Create a hospital language bank

Formalizing the structure of your language bank will help keep things organized. Diversity RX suggests taking the following steps:

Assign a coordinator to assess the language and interpretation skills of employees

Maintain updated lists of bilingual employees

Provide interpreter training

Assess the quality of service provided

In addition, you should include interpretation as a listed job duty, enlist the support and cooperation of supervisors, and provide compensation for bilingual skills as a bonus or differential.

7. Make sure your written language materials are effective

Researchers at Hablamos Juntos found that many hospitals were wasting money on poor translation materials that patients couldn’t use because they couldn’t understand them.

Translation materials should be tailored to the reading level of the audience and adapted and tested for cultural appropriateness. Protocols for translating materials need to be standardized and clearinghouses developed to aid in the dissemination of appropriate and effective materials. Translated forms, documents, and health education materials play an increasingly important role in boosting access to service.

Looking for more?

Some hospitals are already putting interpreter strategies to work

A number of hospitals are already using some of the tips described above. Here are some model programs for hospitalists to look at that reflect different approaches to the provision of interpreter services in a hospital setting:

Jackson Memorial Hospital in Miami, with only two major language groups to serve, has gone with an in-house staff interpreter model.

The University of Massachusetts Medical Center in Worcester also has implemented a staff model, with a strong emphasis on both provider and interpreter -training.

In contrast, hospitals in Seattle found that their diverse patient populations made a shared interpretation program an efficient and cost-effective mechanism for obtaining interpreter services. This led to the development of the Community Interpretation Service, a program sponsored by an outside, nonprofit agency that contracts with the hospitals.

Source: DiversityRX, www.diversityrx.org.