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Limited english proficiency (LEP)

“Individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English can be limited English proficient, or ‘LEP.’ These individuals may be entitled language assistance with respect to a particular type or service, benefit, or encounter.” (U.S. Government, 2011)

According to the United States Census Bureau, the U.S. has an estimated total population of 325 million and approximately 59 million of those people identify as hispanic or latino (2017) --> 70% of those individuals speak spanish.

It can easily be understood how it is a necessity for nurses to know how to communicate efficiently with LEP individuals. I chose to focus on the spanish language population because it is the most common language spoken other than english in the U.S. and hispanics are one of the largest minority populations in U.S.

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Language barrier effects on nursing care of LEP patients in the ED.

“In the United States, a language other than English is now spoken at home in one of five households, the highest level since just after World War I.” (Squires, 2018, p. 21) Communication between nurses and patients is crucial to efficient and safe delivery of care. Language differences serves as a large communication barrier in LEP patients. In the emergency department (ED), this issue can seem more emphasized due to the time constraints or the acuity of care. This is why nurses working in the ED need to understand the importance of breaking those language barriers when they are caring for patients, even when it feels like there is not enough time to involve available resources for language translation.

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Impact of Language Barriers on Patient Outcomes

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Impact of Language Barriers on Patient Outcomes

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(Squires, 2018)

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LEP patient care necessitates utilization of additional resources to provide safe and effective care. When this is not done, errors can easily be made causing patient harm.

In the setting of the ED, nurses may feel they do not have the time to use a translator.

There are times when critical decisions need to be made quickly and there is no time for the allocation of these translating resources.

Because the ED is open 24 hours a day/ 7 days a week, there may be periods of time where accessing translating services will be more difficult than when in other healthcare settings that have more regular business hours.

These reasons create an environment where unauthorized translating means, such as family members, are the most convenient means for what nurses may consider to be effective communication. However, untrained translators can easily mistranslate medical vocabulary and lead to a mistake in care. Because of this, LEP patients are more vulnerable to issues that result from language barriers and communication breakdowns (Schulson, et al., 2018).

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Both the patient and the nurse!

“Limited English proficiency (LEP) patients may be particularly vulnerable in the high acuity and fast-paced setting of the emergency department.” (Schulson, et al., 2018, p. 2113) Patient’s of all cultural backgrounds present to the ED seeking medical care. It is inevitable to encounter an LEP patient in an U.S. ED and it is likely that this individual will be spanish speaking. Each time nurses make interventions for their LEP patients and explain the rationale to the patient or family at bedside, there is an opportunity for miscommunication due to the language barrier. This ultimately prevents the nurse from properly educating, assessing, and communicating with the patient and their family, leaving them susceptible to poor health outcomes. When a nurse practices unsafe care, he or she is at risk for losing their license and causing patient harm.

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In every emergency department and at all times!

Because of the operating hours of EDs, whenever there may be patients then there is a chance for those patients to be LEP and for their care to be compromised by the issues associated with language barriers between the nurse and them.

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HOW DOES THIS ISSUE IMPACT NURSING CARE IN THE ED?

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HOW DOES THIS ISSUE IMPACT NURSING CARE IN THE ED?

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There are multiple parts of the ED nurse’s assessment that require an adequate understanding of what the patient and nurse are saying to each other. If the nurse can’t understand that the patient is describing a certain symptom, takes a particular medication, or has a health history of a disease then this could severely compromise the assessment the nurse makes. The issue of incorrect assessment data leads to ineffective nursing interventions based on false nursing diagnoses. Furthermore, in the ED health care decisions are made more expediently than in other environments and this can exacerbate the already stressed communication circumstance between nurses and LP patients.
So, nurses MUST use translating resources in their care for LEP patients to avoid the issue of unsafe care and patient harm.

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Finding: Inconsistent use of interpreters and increased difficulties with understanding medical information

LEP patients often require the use of translators to adequately understand what their nurses and providers are communicating with them. However, current literature has shows that interpreters are inconsistently used in the ED setting (Schulson, et al., 2018).

“Real and perceived time pressure may make providers less inclined to use interpreters.” (Schulson, et al., 2018, p. 2113)

Even with the use of authorized interpreters, LEP patients have been found to have more difficulty understanding medical information than those who are english proficient (Schulson, et al., 2018). “It is well documented that LEP patients have worse [health] outcomes than their english proficient counterparts. LEP patients have less understanding of their medical conditions and higher rates of ED recidivism.” (Taira & Orue, 2019, p.1)

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Finding: Data shows spanish speaking LEP patients suffer from discrimination in the ED
Literature additionally supports the fact that LEP & spanish speaking individuals fall victim to discrimination in multiple ways while visiting the ED, even in the pediatric specialty. They suffer from statistically longer wait times, they receive less medical interventions when compared to english proficient patients, and they are consistently given lower acuity scores during their triage experience (Connors, 2019). Some LEP parents have confessed that they are not likely to be forthcoming with the fact they don’t speak english well because they are afraid of the discrimination they will receive (Connors, 2019).

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Finding: Large need for verbal and written language assistance in the ED

A recently published study examining LEP population and the use of language assistance resources found that there still is a large unmet need for language assistance in the ED (Taira & Orue, 2019). This not only refers to verbal communication, but also written.

“Hospitals and emergency departments must consider not only spoken language assistance but also written language assistance for LEP patients.” (Taira & Orue, 2019, p.7)

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Current role of the ED nurse in caring for LEP patients:

Luckily, since 1964 there have been forms of legislature addressing the need for accommodations and language assistance with LEP patients (Silva, 2014). These civil rights laws encourage and require all healthcare providers, including nurses, to consider patients' language preference and need for language assistance.

Currently the nurse is one of the first healthcare providers that patient's speak to in the ED that will ask them what their primary language is and if they would like to have an interpreter.

Once this information is obtained, the nurse then documents it in the EMR for future providers to see. (Silva, 2014)

The nurse should then utilize resources available at their facility and the policies in place to accommodate the patient so that there are as little communication barriers as possible.

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(AHRQ, 2012)

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According to the 3rd policy statement on Sentara Healthcare's Language & Communication Services - Patient and/or Companion policy,

"With respect to an individual with LEP, Sentara will take reasonable steps to provide meaningful access to appropriate language assistance services."

(Sentara Healthcare, 2018)

This policy provides nursing staff working at Sentara Healthcare facilities guidelines for addressing LEP patient communication, which molds the role they take in the issue of caring for LEP individuals.

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THE ED NURSE'S INVOLVEMENT IN LEP PATIENT CARE IS IMPORTANT 

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THE ED NURSE'S INVOLVEMENT IN LEP PATIENT CARE IS IMPORTANT 

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Because the nurse is one of the very first providers patients encounter when arriving to the ED, they can set the standard of communication and language assistance for the patient's entire visit by asking them their language preference and, specifically, their english proficiency. They can then document this information in the patient's EMR for future providers to see.

The nurse can also contact the appropriate language assistance/translating resources to use for their initial assessment of the patient. Depending on the facility and type of resource available, that language assistance may be able to stay with the patient for the entirety of their ED visit. This will help lessen the language barrier burden and eliminate time wasted later in the visit determining if the patient needs language assistance resources.

Nurses who are aware of the risks in using unofficial translating resources, such as family members, will be more likely to preemptively gather the necessary language assistance resources whether this be a hospital phone, computer, or an in-house interpreter.

By nature, nurses are patient advocates! Advocating for appropriate language assistance resources for LEP patients is a part of the nurse's duty in caring for the patient.

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CHALLENGES TO THE NURSE'S ROLE IN CARING FOR LEP PATIENTS IN THE ED

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CHALLENGES TO THE NURSE'S ROLE IN CARING FOR LEP PATIENTS IN THE ED

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Use of technology

There are multiple forms of language assistance resources that are technology based and they demand a degree of competency in handling the device being used. There will always be room for user error.

Technological issues such as battery life, network strength, or operating system glitches can occur.

Time constraints in the ED

As pointed out earlier, the ED can be a very pressured and stressful environment fueled by the amount of patients being seen and the variety of acuity levels they fall into.

Both nurses and providers can feel that they don't have adequate time to fully utilize the language assistance resources at their disposal.

LEP patients have difficulty understanding even with interpreters

This remains to be a barrier that may not be overcome by a change in nursing practice. Until communication via language assistance resources is mastered by ED nurses and staff, we may not know why this statistic exists and/or how to fix it.

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EDUCATION ON FACILITY LEP COMMUNICATION POLICIES

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EDUCATION ON FACILITY LEP COMMUNICATION POLICIES

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The nurse should be thoroughly educated and provided with access to the facility's policy regarding care for LEP patients. This will provide the nurse with the standard to use when approaching communication with LEP patients and information on their available resources to enhance communication with the LEP patient.

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EASILY ACCESSIBLE WRITTEN MATERIAL IN MULTIPLE LANGUAGES

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EASILY ACCESSIBLE WRITTEN MATERIAL IN MULTIPLE LANGUAGES

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When working in the ED, the nurse may already feel stressed out over lack of time. Providing readily accessible written health promotion and education materials for patients can save a nurse the time of browsing the facility's databases for relevant translated materials. Also, nurses and providers will be more likely to provide patients with written material in their specific language if it is simple for them to obtain and doesn't add multiple steps to their discharge process.

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COMPETENCY COURSES FOR LANGUAGE ASSISTANCE DEVICES AND APPLICATIONS

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COMPETENCY COURSES FOR LANGUAGE ASSISTANCE DEVICES AND APPLICATIONS

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Nurses and providers will be more likely to use devices such as ipads, tablets, and mobile computers if they have been taught the proper way to use them for language assistance purposes. If they feel confident accessing interpreters via these means, it will not feel like an added chore in their care routine and can become the norm when caring for LEP patients.

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PROGRAMS TO INCENTIVISE USE OF LANGUAGE ASSISTANCE RESOURCES

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PROGRAMS TO INCENTIVISE USE OF LANGUAGE ASSISTANCE RESOURCES

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Because there are great resources available to enhance communication between LEP patients and their nurses, yet we still are seeing inconsistent use of these resources, I believe it would be beneficial for departments initially to create programs to incentivise the use of these resources. I believe that with the continuous evolution of technology coupled with the constant emphasis on the importance of nurses using language assistance resources, within a decade the use of these resources can be normalized so that it will be irregular to care for LEP clients without the use of a language assistance device.

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The first leadership concept I immediately thought of in the context of this issue is the importance of leading by example. Within Sentara's nursing program we are constantly reminded that nurses set a standard for their patients and other nurses through the way they act. I can remember hearing in health assessment class that we can tell our patients all day long to wash their hands or cough away from others and not into their hands, but if they see their nurses not doing either of these things they'll become skeptical of what we teach them and feel like they don't need to listen to our education or advice. Both the patient and other staff members are influenced by a nurse's actions. Therefore, when an ED nurse grabs the MARTTI communication device in the middle of a busy ED shift so that they can better assess the pain level and pain quality that their spanish speaking patient is describing when they point to their abdomen, it will subconsciously remind other staff members that even in the event of emergent situations accurate communication between the patient and the nurse is so crucial! This will also create a culture where the LEP patient is accustomed to using a language assistance device and will feel more comfortable requesting this because it will not feel like an inconvenient or taboo thing.

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Another curricular concept that I can't help but bring up in the context of this issue is the Giger & Davidhizar Transcultural Assessment Model and the communication facet. I guess I didn't realize every time I completed this portion of my care plans that I was effectively memorizing this assessment model and I now feel like I can thoroughly assess a patient's cultural boundaries and traits within the time I complete their head-to-toe assessment. The communication facet of this model begs the importance of identifying how your patient communicates and what is comfortable for them in their culture because the it is important for the nurse to identify this so that he/she can be considerate of it during the duration of their care. So, it only makes complete sense that the ED nurse should always be considerate of the LEP patient's preferred language and utilize their resources to effectively communicate with the patient, both for safety and ethicacy. Being confident in knowing why it is important to address language preference and english proficiency when caring for a patient translates into a leadership quality because it allows me to decide for myself if I need to use a device like the MARTTI to communicate with my patient instead of following the example another nurse might be setting when they feel like they don't need to use language assistance resources.

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Strategies for Overcoming Language Barriers in Healthcare

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Strategies for Overcoming Language Barriers in Healthcare