Vol. 8 Issue 4
Communicating with Languge Barriers
Cultural competence requires that nurses not only be aware of diversity issues but individualize care to avoid barriers and misunderstandings
Let's face it. Being a patient in a hospital can be a stressful encounter even for the most stoic. For patients in the United States who don't speak English, the hospital experience can be threatening, even frightening. Not only does a language barrier compromise a patient's sense of security, the risk that a language barrier will negatively impact the delivery and outcomes of healthcare is very real.
Misdiagnosis, inappropriate medications, poor patient compliance and a decrease in follow-up care are among the detrimental effects reported as a result of language barriers between healthcare providers and patients.1 The financial impact to healthcare resources related to language barriers also is significant. High readmission rates, extended length of hospital stay and difficulty explaining discharge information are all linked to language barriers.2 And, of course, there is an emotional toll. Imagine coping with illness or surgery without the ability to fluidly express emotions, pain or anxiety to a caregiver.
Importance of Being Aware
Communication is at the heart of cultural competence. Whether that communication comes in the form of the spoken word, a listening ear or physical touch, it is imperative that the nurse be equipped with the knowledge of what is culturally expected and desired. Cultural competence can be described as the ability to recognize and respond to our similarities and differences and make better care decisions based on that understanding.
Cultural background influences the way in which people express pain, grief, anger or joy, as well as how they respond to birth, illness or death. The conundrum of a culture and language barrier isn't just experienced by the patient. Nurses, too, admit to the concern of how to communicate with patients in a way they will understand, especially in a way that is culturally sensitive and professionally responsible. Economy of time is essential in administering care and performing patient teaching to balance assignments in the hospital setting. Clearly, it behooves nurses to become experts in utilizing the tools available to successfully meet the needs of their patients who do not speak English.
Focus of Agencies
Addressing the needs of culturally diverse patients and maintaining cultural competency is a key focus for regulatory agencies and nursing organizations, including the American Nurses Credentialing Center, which awards Magnet recognition, and the ANA. JCAHO has strict guidelines that address cultural competence and individualized care for hospitals to fulfill to maintain accreditation3 and in 2001, the U.S. Department of Health and Human Services' Office of Minority Health published National Standards for Culturally and Linguistically Appropriate Services in Health Care.4
Aside from the regulatory agencies that mandate cultural competence, there is a legal obligation. Under Title VI of the Civil Rights Act of 1964, any healthcare provider who receives federal funds must supply a culturally competent translator to someone who does not understand English.1 And the Hill-Burton Act requires hospitals to address the needs of patients who do not speak English.1
About 90 percent of the nurse population is comprised of white females.11 Healthcare providers raised in the U.S. culture often find their medical opinions in conflict with those from a different cultural background.5 These issues serve to further complicate communication when there is an existing language barrier.
Empowering patients with health information they can use and understand will not only improve access to care but outcomes of care. Accurate translation of written teaching materials from English into another language is only the first step in providing culturally sensitive patient educational instruction.
It also is critical to examine cultural norms.6 For example, the practice of teaching a baby to self-feed by holding a spoon is not common practice in Asian cultures. The potential for a clinician to incorrectly diagnose a motor delay in such a scenario is possible unless there is an accurate understanding and communication of cultural norms.
To the contrary, healthcare professionals must be careful not to stereotype patients by simply grouping them into a particular culture based on appearance or race. Further, Flowers reminds us there are subcultures and variations within each culture based on geographical origin, gender, socioeconomic level and educational level.7 While it is helpful to have an overview of cultural norms, a more careful assessment must be made on an individual basis to elicit patient-specific, health-related beliefs and cultural values.8
Undeniably, one of the most helpful strategies a nurse can use when planning and implementing care for a non-English speaking patient is the use of an interpreter. The decision whether to use English-speaking family members rather than a medical interpreter must be carefully weighed. One risk of using an interpreter is that the cultural beliefs may be added or filtered out on the basis of the interpreter's bias.5
In selecting a family member as the interpreter, the issue of disclosure of medical information, particularly disclosure of prognosis, becomes tenuous. Family members may find it difficult to translate such emotional issues with their loved one and, in fact, it may be culturally inappropriate to even speak about a terminal illness in some cultures.9 Additionally, family members may not have adequate knowledge of medical terms and treatment practices to effectively communicate everything to the patient.
Learn Key Phrases
Another strategy that can be employed to communicate with non-English speaking patients is for nurses to learn a few key phrases in the languages most commonly heard in their organization.10 Speaking a few phrases in a patient's native language may help to build trust between the nurse and the patient. It can symbolize the nurse's willingness to connect with the patient and can aid in efficiently meeting the patient's routine needs, such as toileting.
While use of the nursing process offers a framework for the nurse to plan care that will meet the needs of the non-English speaking patient, in culture nursing assessment, nurses look not only at the richness of diversity but also the similarities between the dominant healthcare belief system and the individual's beliefs and practices. A thorough culture assessment can take a few hours, but nurses rarely find time to accomplish this goal. At a minimum, nurses should determine the major factors to consider in the plan of care. Identifying such information as the patient's primary language, proficiency level with English, country of origin, support people, religion, health beliefs and food preferences is a helpful starting point.
Awareness Not Enough
Frusti et al. encourage nurse administrators to actively engage in skill building, moving beyond simply the awareness of diversity.11 Reynolds speaks of the need for "cultural desire" to increase among healthcare providers to improve communication and better understand diverse patient groups.5 There is no room for an ethnocentric viewpoint in holistic nursing care.
Cultural competence must be a commitment made by nursing professionals to provide optimal patient outcomes and assure professional accountability. Not only do nurses need to be familiar with the cultural norms for the patients in their care, but they must carefully avoid cultural stereotypes and strive to be open-minded and nonjudgmental in formulating plans of care.12 Failure to individualize care may create unintended barriers to providing excellent, respectful nursing care.
1. Romero, C.M. (2004). Using medical interpreters. American Family Physician, 69, 2720-2722.
2. Brooks, N., et al. (2000). Asian patients' perspective on the communication facilities provided in a large inner city hospital. Journal of Clinical Nursing, 9, 706-712.
3. Joint Commission on Accreditation of Healthcare Organizations. (2003). Hospital accreditation standards (Rev. ed.). Oakbrook Terrace, IL: Author.
4. U.S. Department of Health and Human Services, Office of Minority Health. (2001, March). National standards for culturally and linguistically appropriate services in healthcare. Retrieved July 1, 2005 from the World Wide Web: http://www.omhrc.gov/omh/programs/2pgprograms/executive.pdf
5. Reynolds, D. (2004). Improving care and interactions with racially and ethnically diverse populations in healthcare organizations. Journal of Healthcare Management, 49(4), 237-248.
6. Coyne, C. (2001). Cultural competency: Reaching out to all populations. PT Magazine, 9(10), 44-50.
7. Flowers, D.L. (2004). Culturally competent nursing care; a challenge for the 21st century. Critical Care Nurse, 24(4), 48-52.
8. Yeo, S., Fetters, M., & Maeda, Y. (2000). Japanese couples' childbirth experiences in Michigan: Implications for care. Birth, 27(3), 191-198.
9. Hanssen, I. (2004). An intercultural nursing perspective on autonomy. Nursing Ethics, 11(1), 28-41.
10. Green-Hernandez, C., et al. (2004). Making nursing care culturally competent. Holistic Nursing Practice, 215-218.
11. Frusti, D.K., Niesen, K.M., & Campion, J.K. (2003). Creating a culturally competent organization. The Journal of Nursing Administration, 33(1), 31-38.
12. Walsh, S. (2004). Formulation of a plan of care for culturally diverse patients. International Journal of Nursing Terminologies and Classifications, 15(1), 17-26.
Ngoc Godshall is patient-community educator at the Learning Institute, and Kimberly Fenstermacher is a project coordinator at PinnacleHealth System, both in Harrisburg, PA.