Improving Care for Patients with a Non-English Language Preference (NELP)

Authors: Natalie Hernandez, MD, MPH, (Harbor-UCLA Medical Center Department of Emergency Medicine); IV Mirus, MD (Assistant Professor of Emergency Medicine, UT Southwestern Medical Center); Manpreet Singh, MD, MBE (Director, Undergraduate Medical Education, Harbor-UCLA Medical Center Department of Emergency Medicine) // Reviewed by: Brit Long, MD (@long_brit

You walk into a patient room to find the patient has brought a family member to interpret for them. How do you respond? What are some important considerations to optimize your communication?

What does it mean to have a non-English language preference (NELP)?

You may be more familiar with the term “limited English proficiency” (LEP), defined as: someone who does not speak English as their primary language and has a limited ability to read, speak, write, or understand English.¹

However, we recognize that many patients prefer to speak a language other than English regardless of their English proficiency, and this does not indicate a deficiency. Thus, modern movements in language justice prefer to use the term “non-English language preference”.

The United States does not have an official language, though English is most commonly spoken. Over 25 million individuals in the U.S. have limited English proficiency according to the 2015 U.S. Census.² These individuals are protected against discrimination under various federal, state, and organizational laws and regulations.^3,4 Notably, institutions receiving federal funding (such as hospitals receiving Medicare reimbursement) must abide by Title VI of the 1964 Civil Rights Act, which entitles persons with NELP to language assistance.⁵

Despite these protections, NELP patients face numerous health disparities compared to their English-proficient counterparts. Studies have shown that NELP patients are:

• More likely to have a longer waiting room length of stay.⁶
• 24% more likely to return to the ED within 72 hours of their initial visit in an urban ED with >50,000 annual visits.⁷This has also been observed in a pediatric patient population.⁸
• Nearly four times as likely to provide an incorrect medication dose to their child.⁹
• Less likely to be satisfied with their care and have a lower understanding of their discharge instructions.¹⁰
• Three times as likely to have poor health literacy (44.9% vs 13.8%).¹¹
• Unlikely to receive language assistance. One cohort study in a public ED found that 84.5% of individuals with NELP who requested spoken language assistance did not receive it.¹²

How do we address these disparities in the emergency department?

As providers, we must advocate for systemic and individual changes to improve care for NELP patients. Utilizing a multifaceted approach has been demonstrated to improve language access in a public ED.¹³ Interventions may include:

1. Ascertaining a patient’s preferred language early in the clinical encounter (during registration, for instance), and clearly documenting this preference in a place that is visible to all providers. This includes correcting the preferred language if it is listed incorrectly.
2. Educating patients on their rights. For instance, displaying posters in multiple languages that explain the language services patients are entitled to.
   • The Affordable Care Act (ACA), Section 1557 explicitly prohibits discrimination based on national origin, including language access issues, in any healthcare program or activity receiving federal financial assistance. This provision extends language access rights to NELP individuals and requires healthcare providers to offer language assistance services such as professional interpreters, translation of vital documents, and communication of the availability of language services.¹⁴
   • Similarly, the American Disabilities Act (ADA) mandates equal access to healthcare services for individuals with disabilities, including those with communication disabilities related to NELP. The ADA requires healthcare providers to make reasonable modifications to policies and procedures to ensure effective communication with individuals who have disabilities, including the provision of qualified interpreters and other auxiliary aids and services. This is commonly seen with Deaf patients who communicate using American Sign Language and require an ASL interpreter.¹⁵
3. Ensuring bilingual providers are tested and credentialed. Well-meaning providers who are not highly fluent may contribute to miscommunication and diagnostic errors.
4. Utilizing certified interpreters and documenting their use.
   • Certified interpreter use can improve communication and patient outcomes.¹⁶ Benefits include:
     • Accuracy and language proficiency: Professional interpreters undergo specialized training and possess excellent language skills, including medical terminology. They are proficient in both the patient’s language and English, ensuring accurate and precise communication without omitting or altering critical information.
     • Cultural competency: Formal interpreters are trained to navigate cultural nuances and respect patient confidentiality. They understand the importance of maintaining professional boundaries and confidentiality during medical encounters.
     • Impartiality: Professional interpreters maintain a neutral and unbiased position, allowing for objective interpretation. They do not have personal relationships or vested interests that could impact communication, ensuring the integrity of the conversation.
     • Ethical standards: Formal interpreters follow a code of ethics, which includes principles such as confidentiality, accuracy, and impartiality. These standards promote the highest level of professionalism and quality of interpretation.

• • To avoid common errors, providers should remember the following while working with an interpreter:¹⁷
    • Address the patient directly. For instance, face the patient, make eye contact, and address them as “you”.
    • Monitor your body language and be attuned to your patient’s nonverbal communication – clarify or ask follow up questions if your patient appears surprised or confused. Nonverbal cues are even more important when communicating with Deaf patients. Having a welcoming posture and expression will provide a positive tone to the interaction.
    • Speak clearly and concisely, especially while using a phone or video interpreter.
    • Pause between statements to allow for accurate interpretation (unless you are using a simultaneous interpreter).
    • If the patient is speaking without pausing, remind them (via interpreter) to allow time for interpretation.
    • Minimize communication barriers with the use of an in-person interpreter, when possible.

5. Avoiding the use of ad hoc interpreters and untrained ED staff, unless explicitly requested by the patient. A patient’s friends and family may assist with cultural barriers and provide emotional support. While convenient, the use of ad hoc interpreters (including untrained staff) offers several drawbacks that contribute to disparities:¹⁸
   • Inaccurate communication: Ad hoc interpreters may lack fluency in both languages and may not be familiar with medical terminology. This can lead to miscommunication, omissions, and potential harm to the patient.
   • Conflict of interest: Family members or friends acting as interpreters may struggle to maintain impartiality due to their emotional relationship with the patient. They may alter information based on personal biases or concerns, potentially hindering effective communication and jeopardizing patient care.
   • Privacy and confidentiality: Sensitive or confidential information may be shared with family members or friends unintentionally, potentially causing discomfort and violating the patient’s privacy.
   • Legal and ethical considerations: Relying on ad hoc interpreters may raise legal and ethical concerns, particularly regarding informed consent, privacy regulations, and the potential for miscommunication leading to medical errors or liability issues.

Given the above points, providers should always offer a certified interpreter. However, some patients will still prefer interpretation via a family member or friend. Providers should respect and utilize this mode of communication, as well as document the patient’s request for a non-certified interpreter.

6. Educating staff regarding language rights, certified interpreter use, language-congruent patient documentation, and cultural humility. One study from a public ED serving predominantly NELP patients found that most providers were unaware of hospital policy for language assistance, and most had not previously received training regarding interpreter use. In addition, most providers utilized other ED staff and ad hoc interpreters rather than certified interpreters when working with NELP patients.¹⁹
   • Listed below are tools you can use to inform language justice interventions in your ED.
     • Advocate for your department to obtain a HIPAA-compliant mobile phone interpreter app if in-person or phone interpreters are not readily available. Some examples include LanguageLine Insight Solutions, MediBabble, Care to Translate, and VerbalCare, in no particular order.
     • Train your staff on how to use an in-person interpreter effectively with videos such as this one created by the Stanford School of Medicine.
     • Train your staff on best practices for using phone interpreters. Pacific Interpreters has an informative Youtube video with key tips and tricks.
     • Review toolkits and studies that provide strategies for advancing language justice in your ED:
       1. Betancourt JRRM, et al. Improving patient safety systems for patients with limited English proficiency: a guide for hospitals. Rockville: Agency for Healthcare Research and Quality. 2012. 12-0041.
       2. Lion KC, et al. Evaluation of a quality improvement intervention to increase use of telephonic interpretation. Pediatrics. 2015. 135:e709-e716.
       3. Regenstein M, et al. Improving the quality of language services delivery: findings from a hospital quality improvement initiative. J Healthc Qual. 2012. 34(2):53-63.
       4. Taira B, et al. Hospital and health system-level interventions to improve care for limited English proficiency patients: a systematic review. The Joint Commission Journal on Quality and Patient Safety. 2019. 45:446-458.
       5. Taira B, et al. An implementation science approach improves language access in the emergency department. Journal of Immigrant and Minority Health. 2021. 23:1214-1222.

• • • The interpreting services listed above are examples and not endorsements. There are no financial disclosures.

7. Approaching each patient encounter with cultural humility. Contrary to cultural competence, cultural humility focuses on empathy and lifelong learning rather than memorizing often stereotypical aspects of diverse backgrounds. In addition, through addressing our implicit biases, we can improve communication and quality of care. There are several tools that help us identify our implicit biases and bring cultural humility into our daily practice.^20,21
8. Advocating for policy changes improving language access in your department and institution.
9. Conducting research regarding best practices for improving health outcomes for NELP patients.²²

Case Conclusion

You educate the patient on their right to a professional interpreter to ensure accurate communication, and they accept. You emphasize the importance of involving the family member in conversation if the patient wishes, which facilitates rapport building and cultural understanding. You document the use of interpreting services in your note. You provide updates and discharge instructions in the patient’s preferred language. The patient demonstrates an excellent understanding of their care and plan. They thank you for your service, and you are confident that they will follow through with your instructions and heed your return precautions.

Pearls

• NELP patients have worse health outcomes despite widespread language-access policies.
• There are various local and federal policies ensuring the rights of NELP patients to healthcare language services.
• Recognize and respect the autonomy of NELP patients in their decision-making process.
• Prioritize the use of professional interpreters to ensure accurate communication.
• Apply cultural humility and acknowledge implicit biases to enhance patient-centered care.
• Improving outcomes for NELP patients requires a multifaceted, systematic approach that includes provider education and easily available language services.

References

1. Language access during the COVID-19 pandemic & other health emergencies. U.S Department of Homeland Security, Office for Civil Rights and Civil Liberties; Federal Emergency Management Agency, Office of Equal Rights; U.S. Department of Health and Human Services, Office of Civil Rights. 2023. Slide 7. Link.
2. Zong J and Batalova J. The limited English proficiency population in the United States in 2013. Migration Policy Institute, Migration Information Source. July 2015. Link.
3. Patient centered communication standards for hospitals. R3 Report Requirement, Rationale, Reference; a complimentary publication of the Joint Commission. February 2011. Link.
4. Youdelman M. Summary of state law requirements addressing language needs in health care. National Health Law Program. April 2019. Link.
5. Limited English proficiency. U.S. Department of Health and Human Services. Link.
6. Lim T, Campbell R, et al. Association of limited English proficiency and increased emergency department waiting room lengths of stay. Annals of Emergency Medicine. October 2022. Link.
7. Ngai K, Grudzen C, et al. The association between limited English proficiency and unplanned emergency department revisit within 72 Hours. Annals of Emergency Medicine. August 2016. Link.
8. Samuels-Kalow M, Stack A, et al. Parental language and return visits to the emergency department after discharge. Pediatric Emergency Care. June 2017. Link.
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13. Taira B, Onofre L, et al. An implementation science approach improves language access in the emergency department. Journal of immigrant and minority health. December 2021. Link.
14. Section 1557 of the Patient Protection and Affordable Care Act. U.S. Department of Health and Human Services. Link.
15. Mirus I, Rotoli J, et al. My patient is Deaf. What should I know? emDocs. November 2021. Link.
16. Karliner L, Jacobs E, et al. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. April 2007. Link.
17. Johnson L, Mirus I, et al. Language accommodation: best practices for working with interpreters. SAEM Pulse. May-June 2023. Link.
18. Johnson L, Mirus I, et al. Language accommodation: best practices for working with interpreters. SAEM Pulse. May-June 2023. Link.
19. Taira B, Torres J, et al. Language assistance for the care of limited English proficiency (LEP) patients in the emergency department: a survey of providers and staff. Journal of Immigrant and Minority Health. June 2020. Link.
20. Masters C, Robinson D. Addressing biases in patient care with the 5Rs of cultural humility, a clinician coaching tool. Journal of General Internal Medicine. January 2019. Link.
21. Betancourt J, Green A, et al. Defining cultural competence: a practical framework for addressing racial.ethnic disparities in health and health care. Public Health Reports. July-August 2003. Link.
22. Taira B, Kim K, Mody N. Hospital and health system-level interventions to improve care for limited English proficiency patients: a systematic review. Joint Commission Journal on Quality and Patient Safety. June 2019. Link.