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Patients rely on nurses to make care information understandable
Language remains a barrier for some
EDITOR'S NOTE: Nancy J. Brent, MS, JD, RN, brings more than 30 years of experience to her role as Nurse.com’s legal information columnist. Brent’s posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state.
In today’s healthcare facilities, more and more individuals seek medical and surgical treatment who do not speak English or have limited English proficiency.
The solution to providing care to these individuals is often using family members who understand more English as “interpreters.” Unfortunately, this solution can result in medication errors, wrong procedures and other adverse events.

According to the Agency for Healthcare Research and Quality, nearly 9% of the U.S. population is at risk for an adverse event due to language barriers. The real solution to providing care to these individuals is compliance with legal mandates that ensure, insofar as possible, that language is not a barrier to patients' understanding and giving informed consent for care.
The ultimate mandate for “language access” rests with Title VI of The Civil Rights Act of 1964, which says, “No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of or be subjected to discrimination under any program or activity receiving federal financial assistance.” Congress passed this act to ensure no federal monies were used to support discriminatory programs or activities. Since 1974, the U.S. Supreme Court has treated language discrimination as equal to national origin discrimination. Moreover, the federal government’s many agencies, regulations and policies also have treated language as a substitute for national origin, including the Department of Health and Human Services. The federal mandate for language access also is supported by 50 states and their respective case law decisions. Compliance with these legal mandates most often takes the form of using qualified medical interpreters. The ideal situation is when there is face-to-face interpretation with the patient by the interpreter. However, this is not only costly, it is sometimes logistically impossible. A U.S. research study conducted in a large academic medical center in the Midwest, underscored these difficulties. The study explored patients’ understanding about the use of their call light at two adult med-surg units with high numbers of patients with limited English proficiency.
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Requirements for the RNs in the study included: their ability to communicate in English, being employed as a staff nurse for at least 12 months, working at least 50% as regular staff providing patient care and providing care for patients with limited English proficiency at the study site. Six themes emerged from the researchers’ qualitative data analysis. I’ll highlight two of those themes here. The first theme was barriers to communication. The RNs identified difficulty in knowing how much English the patients really understood, especially when it was “broken English.” In addition, the RNs described their frustration with impressing upon the patient the importance of the call light and its use. In one instance described in the study, a patient went without food for about 10 hours because the nurse thought the patient would use the call light after instructing him to do so, and the patient never asked for food because he was not able to tell her of his hunger. In addition, since the call lights were not used as they were needed because of communication barriers, adequate care could not be provided to the patients. One example given was the need for the patient to use the call light when he or she required assistance with getting out of bed or ambulating. A second theme was formal tools for communication. These tools were provided and approved by the facility. Visual aids (e.g., flash cards) were of some help to RNs, but the cards were not always available. In-person interpreters were available at the facility, but not often readily. In addition, because the number of interpreters was limited at the facility, they were difficult to obtain when needed. The RNs had access to an interpreter phone which they used to access a specific language interpreter. According to the study, they used the phone more than the in-person option because it was more readily reliable. There are more interesting details in the study about how the RNs worked with limited English proficiency patients.
Reviewing your facility’s policies and procedures governing the use of certified interpreters and following them.
Its implications, along with the legal mandate for “language access,” has recommendations for med-surg nurses. These proposals include:
Utilizing tools available in the facility for those with limited English proficiency or those who do not speak English as their primary language (e.g., flash cards, online programs, computer videos and discs).
Contacting your risk manager to obtain information on your state’s laws applicable to language access and seek help in how to meet those requirements in your facility.
When caring for a patient who has limited English proficiency or who is a non-English speaking, patient, ensure your nurse manager and physician are informed.
Advocate for a certified interpreter for any patient who needs interpretation services and has no identified interpreter.
Remember language access is not only limited to verbal communication — where possible, written forms in the patient’s language should be used as well. Regardless of whether the patient does not use English as a primary language or is limited in its proficiency, the Academy of Medical-Surgical Nurses notes in its Health Literacy Position Statement you should evaluate all patient learners on a consistent basis and provide written educational materials at the fifth-grade level and in the patient’s primary language when possible.
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By Nancy J. Brent
MS, JD, RN
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