Limited English proficiency and adverse event risk.

As a native San Franciscan, I grew up surrounded by bilingual people who represented cultures from all over the world. It is a privilege for me to be surrounded by such rich diversity, but many patients who are limited English proficient (LEP) are at risk for adverse events once they enter a health care setting. Identifying a patient’s preferred language at the initial point of entry can ensure that resources are available to support the patient as they navigate the health care system. Medical interpreters are vital to our LEP patients and serve as a bridge for translating both language and other crucial cross-cultural elements of communication.

Letting patients and families know their rights.

Providing interpreting services reduces health inequities for LEP patients and is also required by Title VI of the U.S. Civil Rights Act (1964). This law states that hospitals that receive funding from the U.S. Department of Health and Human Services must notify LEP patients of the availability of free interpreting services, which should not include their own friends and family. As nurses, we must advocate for our patients who may not be aware of their rights and may have fears about perceived consequences if they admit to not being proficient in English. Perform a quick scan of your clinical environment and patient paperwork—is it LEP friendly?

I am a nurse at an academic medical center that provides tertiary care to adults and children from all over the world. We have patients who speak “rare” languages and we are often challenged to coordinate services with an interpreter who is in high demand and often serving the entire country. I collaborated with interpreting services and a pediatric surgery work group to identify that patients with specialized interpreting needs should be scheduled as the first case of the day and provided a separate appointment with an interpreter to complete the consent, especially for complex surgeries. In this work group, it was also identified that health care staff could benefit from learning about best practices for when they work with a medical translator. We can offer phone, video, and in-person interpreting services based on the level of patient need.

Certified medical interpreters.

By Rihards Sergis/Unsplash

Certified medical interpreters are highly skilled can ensure a lower risk of medical errors for our LEP patients. For any conversation that goes beyond “non-vital” activities of daily living, a certified interpreter is required. If staff are bilingual, they may apply for certification to act as interpreters for their own patients.

Certified medical interpreters are screened for linguistic competence, which means they are fluent in the source and target language and have the ability to interpret speech from one language to another. They are trained to interpret verbal and nonverbal communication, which can reduce the risk of bias, misunderstandings, confusion, and frustration. This is why using friends and family to translate can be dangerous. Certified medical interpreters are trained to be impartial and not let their own values, beliefs, and opinions interfere in the communication process.

The pediatric surgery work group identified a need to educate clinicians on how to access and schedule interpreting services as well as best practices once an interpreter is present. I created an e-learning module to help disseminate these tips to all clinicians who interacted with patients regularly.

Tips and best practices.

These tips and best practices can be helpful for you, your patient, and the interpreter to ensure a successful interaction:

  • Document and identify the patient’s preferred language for health care in the electronic health record as a shared resource for all team members.
  • Use a tool to assist the patient and staff in identifying their preferred language (see example).
  • If an in-person interpreter is not available, test the audio and microphone of the device you will be using.
  • Try to let the interpreter know what to expect before starting the conversation.
  • Assume, and insist, that everything said in the encounter by anyone present will be interpreted.
  • Speak to the patient, not the interpreter: Use the second person (“Do you….?”), not the third person (“Does she….?”). You are not talking at the patient, but with the patient.
  • Attempt to normalize the experience for the patient. Face them and maintain eye contact.
  • Be careful with humor and idiomatic expressions—they probably won’t translate well.
  • Keep a comfortable pace that allows time for interpretation (consecutive or simultaneous). Speak slowly, rather than loudly.
  • Use an appropriate level of language complexity. Lack of English proficiency is not an indication of low cognition; avoid assumptions about a lack of formal education.
  • Cultural considerations: a patient nodding, saying “yes,” or smiling may indicate listening or respect rather than understanding. Gestures vary in meaning from culture to culture.
  • Organize your thoughts before speaking. Sentence fragments, complex sentences, and changing your mind mid-sentence can be confusing.
  • Be prepared to repeat, rephrase, and summarize. Be patient.
  • Ask patients to “teach back” what was said to assess for understanding, as you do with your English-speaking patients.
  • For any important conversations that the nurse charts about, document that an interpreter was used and identify the interpreter, either by name or the ID code they give you.

Anjal Pong, DNP, MSN, RN, NPD-BC, is a nursing professional development specialist at the Center for Nursing Excellence and Innovation, University of California, San Francisco (UCSF). She has had over 20 years of clinical experience in the operating room, been a leader for the Evidence-Based Practice Nursing Fellowship Program, and served as coach for the professional development shared-governance council.