Impact of Language Barriers on Patient Safety
Submitted by Edith Claros, PhD MSN
Written by: Eva Vega-Gamez, Stephanie Dumesle, Jinsol Kim, Mayara Silva, and Edith Claros, PhD MSN RN
Over the last decade, worldwide migration has increased by 50% (as cited in Boylen, Wilson, Gill, Cherian, & Dantas, 2017). The United States was one of the countries with the largest number of migrant residents. According to the U.S. Census Bureau, nearly 25 million people in the U.S. have limited English proficiency (LEP) (as cited in Wasserman et al., 2014). Therefore, effective communication with a LEP patient becomes central to the provision of successful care. Communication errors were the root cause of 59% of serious adverse events reported to the Joint Commission (Wasserman et al., 2014). Linguistic differences between healthcare providers and patients, may cause higher prevalence of adverse events (Montie et al., 2016). An analysis of adverse incidents in the hospital setting revealed that 49.1% of LEP patients endure physical harm, compared to 29.5% of English-speaking patients (Hu, 2018). Communication is the key to provide safe patient care in the healthcare setting as it facilitates a clear exchange of information between patients and providers. Patients with linguistic differences may struggle to advocate for themselves and may not be able to explain their chief complaints or express their level of pain. Therefore, LEP patients are at higher risk for complications because of poor comprehension of increased medication errors, inaccurate assessment, and poor treatment and follow-up compliance.
Consequences of Language Barriers
There are many ways in which language barriers can be addressed. However, these techniques are not enough to prevent problems with communication. Availability of new technology to empower patients to actively participate in their care, is not always available due to limited hospital budgets. Professional medical interpreters are available and can alleviate some communication barriers, however, they may not necessarily prevent patient safety risks (Ali & Watson, 2018). Interpreting services may also stifle the nurse-patient relationship, as speaking through an interpreter is not as effective or satisfying as having a direct conversation with a health care member (Ali & Watson, 2018). Not having access to an interpreter can lead to serious consequences. For instance, a patient in California underwent a nephrectomy in which the healthy kidney was removed instead of the diseased one. It was discovered that the patient signed a consent form in English and was not provided an interpreter (Goodwin, 2018). Medical errors are prevalent due to the inappropriate use or disregard of interpreting services (Goodwin, 2018).
Standard of practice dictates that when administering a medication, both name and date of birth should be verbally confirmed by the patient. However, when the patient does not speak English, verification before medication administration is often disregarded (Rosse, De Bruijne, Suurmond, Essink-Bot, & Wagner, 2016). Rosse et al. (2016) discovered that medication errors are responsible for a great portion of adverse events in the hospital setting. It is especially prevalent in patients with a language barrier compared to patients with English proficiency (Rosse et al., 2016). Although professional interpreters are the primary intervention to decrease the communication gap that may contribute to medication errors, ad hoc interpreters, such as family members or friends, are also frequently used. Ad hoc interpreters are unfamiliar with the safety risks associated with medications and thus may impact the quality of care by misinterpreting pertinent information (Boylen et al., 2017). Therefore, the use of unprofessional interpreters can result in increased medication errors and can indirectly hamper patient safety.
Another essential aspect of care surrounding medication is patient education regarding new prescriptions. In a cross-sectional study of nurses, 90% of participants believed that communication was essential when providing education about a new medication (Bowen, Rotz, Patterson, & Sen, 2017). Out of all surveyed nurses 41% believed that language barriers negatively impacted nurse-patient communication during patient teaching (Bowen et al., 2017). And nurses expressed low confidence that patients understood how to manage their medication regimen due to their linguistic differences.
LEP impacts all aspects of care, including assessment. Another safety issue related to patients that have limited English proficiency is pain management (Rosse et al., 2016). A great deal of patient teaching is involved when explaining the pain scale. When patients do not understand how to rate their pain because of their limited comprehension of English, the reported pain level may be inaccurate. Pain and distress can also be described in different ways by different cultural groups (Meuter, Gallois, Segalowitz, Ryder, & Hocking, 2015). Because pain is subjective, miscommunication can greatly impact quality of care (Rosse et al., 2016). The inaccurate pain rating can lead to either overmedication or undermedication, which may result in poor pain management (Rosse et al., 2016).
Similarly, there are multiple health conditions that require the strict measurements such as urine, stool, and daily fluid intake of a patient. To be able to accurately measure intake and output, it is essential that the patient can correctly utilize the necessary instruments, such as a urinal or urine collection hat. Inaccurate measurements greatly impact the course of treatment prescribed, which may lead to the exacerbation of existing conditions. Incorrect fluid balance management can lead to adverse outcomes, such as dehydration and renal or heart failure, and inappropriate treatment plans that can greatly impact the overall patient health (Rosse et al., 2016) and quality of life.
Treatment and Follow-up
The patient with linguistic differences, may experience an increased level of psychological stress that can lead to significant errors. LEP patients are more likely to miss appointments, making treatment and follow up difficult (Ali & Watson, 2018) and less likely to understand their treatment regimen, impairing adherence (Ali & Watson, 2018). If a patient does not understand a new diagnosis, or if a provider is not able to accurately explain the associated risk factors, the patient is not likely to make informed decisions, which may be life threatening (Meuter et al., 2015). Comprehending medical information represents a challenge for any patient. Language barriers can negatively impact a patient’s health literacy (Murray, Elmer & Elkhair) making it more challenging for the patient to understand, often times, complex medical diagnoses and treatments (Hu, 2018). These challenges can contribute to the adverse outcomes due to poor communication among the patient and the provider (Hu, 2018).
Many healthcare settings offer professional interpreting services to accommodate the limited language comprehension among LEP patients, but it is not without limitation. It does not completely replace direct communication and may contribute to significant safety risks (Ali & Watson, 2018). It hinders patients from becoming an active participant in their own care, forcing them into a more passive role. Patients and healthcare workers reported a disconnect because neither side was certain that their interactions were being interpreted appropriately (Steinberg, Valenzuela-Araujo, Zickafoose, Kieffer, & DeCamp, 2016). The formation of a trusting relationship between the healthcare worker and the patient was impeded, making follow up care difficult.
The communication gap between LEP patients and healthcare workers may result in more frequent emergency department visits and increased readmission rate (Boylen et al., 2017). Statistics show that hospital 30-day readmission rates are higher among LEP clients and that there is a delay in care for non-English speaking patients (Goodwin, 2018).
Role of Nurses in Enhancing Communication
Hospital administration has taken steps to decrease the impact of language barriers with LEP patients. Language barriers can lead to ineffective communication with healthcare providers, which in turn, can lead to uncertainty, stress, and hurdles that affect the implementation of culturally competent and patient-centered care (Ali & Johnson, 2017). In order to provide holistic care, it is important to adapt care models to fit the patient’s culture and language preference (Shesser, 2017). A study conducted by Ali and Johnson (2017) explored the impact of the bilingual nurse in providing language concordant care to LEP patients. Nurses who were involved in the study were able to speak at least one other language fluently, which proved to be an asset when caring for the LEP patients. Speaking the same language with the patient can provide them with comfort and reassurance, enhanced nurse-patient relationship, improved treatment compliance, higher patient satisfaction, decreased cost of care, and fewer emergency room visits (Ali & Johnson., 2017). It facilitates the development of trust and gives the patient a chance to communicate their needs effectively and directly to the nurse. Providing care to patients in their primary language can enhance the healthcare experience of the patient whilst also being an invaluable asset to the healthcare team (Ali & Johnson., 2017). It highlights the importance of providing language concordant care.
It is important to make the patient an active participant in their care and to provide culturally congruent care (Shesser, 2017). Title VI of the Civil Rights Act of 1964, under Federal and state law require that health care organizations that receive Medicare and Medicaid reimbursement take reasonable steps to provide language assistance services to LEP, Deaf and Hard of Hearing patients that is free of charge, accurate, timely and in accordance with HIPAA guidelines (U. S. Department of Health and Human Services [DHHS], n.d). A program established by Children’s Hospital of Philadelphia attempts to bridge the gap in LEP patient-provider communication. It provides professional interpreter services rather than relying on ad hoc interpreters, recognizing that it may lead to preventable serious medical errors and miscommunication (Shesser, 2017). Nurses provide bedside inpatient teaching prior to discharge, in order to assess the patient and family’s understanding of medications, medical equipment use, and treatment, allowing the patient to demonstrate skills and ask questions. Visiting nurses are able to provide linguistically appropriate continuity of care by performing medication reconciliation, assessing treatment adherence, and inspecting the environment for safety risks (Shesser, 2017).
It is difficult for nurses to establish a trusting relationship and to provide individualized care when language barrier is present. Although professional telephone or in-person interpreting services are available in healthcare settings, LEP patients and families have reported that they often do not receive language services. Lack of awareness regarding the communication barrier between nurses and LEP patients can lead to improper use of resources, potentially contributing to severe consequences. The communication gap can result in compromised quality and safety and increased medical errors. Therefore, it is important for all nurses, present and future, to acknowledge linguistic differences with LEP patients to prevent further health disparities.
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