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Story Publication logo November 20, 2023

How Nurses Overcome Challenges While Treating Patients With Limited English Proficiency

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The pandemic left the nursing profession in a state of crisis. How are hospitals, health systems and...

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Video courtesy of PBS NewsHour.

The increasing diversity of the U.S. brings an array of challenges, including the basic hurdle of not speaking the same language. The stakes are especially high in a medical setting. In collaboration with the Global Health Reporting Center and with support from the Pulitzer Center, William Brangham looks at how nurses are meeting the moment for our series, Critical Care: The Future of Nursing.

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Geoff Bennett: Among the many challenges facing the country's health care system: language barriers, when patients and providers speak different languages.

In collaboration with the Global Health Reporting Center and with support from the Pulitzer Center, William Brangham looks at how nurses are meeting the moment.

It's part of a series Critical Care: The Future of Nursing.

William Brangham: Julio Oreana (ph) speaks no English and received medication from a pharmacist who spoke no Spanish. He did not know what the medication was for, and so he had not taken any.

Cristina Melgar, Nurse, La Clinica Del Pueblo (through interpreter): OK. Let me see the pills that you have.

William Brangham: Nurse Cristina Melgar tells him how to take it and offers a little encouragement.

Cristina Melgar (through interpreter): Of course, if you have any problems, you know you can come here.

William Brangham: Melgar says, in addition to providing medical care, traversing these language barriers is a crucial part of her job.

Cristina Melgar: So, the system for rife with patients who are not fluent in English. They feel neglected. They feel not treated with respect sometimes.

William Brangham: Melissa Marinelarena oversees the nurses here at La Clinica Del Pueblo, the Clinic of the People, in Washington, D.C.

Most of the staff speak fluent Spanish, something she says is a critical part of delivering top-shelf care.

Melissa Marinelarena, La Clinica Del Pueblo: There is literature out there and that backs up the fact that patients want to be taken care of by providers that look like them, that speak the same language as them, and by providers that sound like them.

And, unfortunately, right now, there's not enough of us out there.

William Brangham: Most clinics and hospitals are legally required to provide interpretive services, based on the Civil Rights Act of 1964, and the rule was strengthened in the Affordable Care Act.

While communication is just one of many factors that affect the quality of care, studies show that language gaps on their own can lead to worse outcomes.

Allison Squires, NYU Rory Meyers College of Nursing: Any time you have a harmful event happen to you in the hospital, those harmful events, the risk for people with limited English proficiency can be 15 percent to 25 percent higher than people who speak English.

William Brangham: Allison Squires is a professor of nursing at New York University. She studies what happens to patients who don't share the same language as their providers.

Allison Squires: So they are at higher risk for experiencing harm during a hospitalization. They are less likely to get timely access to primary care. They also are more likely to have a longer length of stay.

So all of these things actually add up in terms of overall health care costs to the patient, to health systems, to insurance companies, everything.

William Brangham: Squires published a study of more than 90,000 patients who were released from hospitals with follow-up care back home. She found those with limited English were more likely to end up back in the hospital, only 1 percent, but still.

Allison Squires: I know 1 percent doesn't sound like a lot in terms of an increased risk, but that 1 percent can compound into millions of dollars, especially if you're serving a lot of patients over time.

William Brangham: The Hispanic population is growing three times faster than the U.S. population as a whole. About 14 percent of the U.S. population speak Spanish at home, and yet only 6 percent of working nurses are Hispanic.

Melissa Marinelarena: It's all very different. And understanding, yes, the different dialects in Spanish, the different accents in Spanish is very different as well.

What we are doing here at La Clinica is just a drop in the bucket.

William Brangham: The challenge isn't limited to just Spanish. About one in 12 Americans speaks limited or no English. Three in five are Spanish speakers. The rest speak Chinese, Tagalog, Vietnamese, Arabic, and other languages.

At the Cizik School of Nursing at UTHealth Houston, they are making it a priority to build a work force that better matches the patient population.

Erica Yu is a professor and associate dean.

Erica Yu, Cizik School of Nursing, UTHealth Houston: Forty-seven percent of our undergraduate nursing students are underrepresented minority. And our total student percentage is 46 percent of our total students — that means including graduate students — are an underrepresented minority.

And 35 percent of our students are Hispanic, which is very different from the national picture.

William Brangham: Professor Elda Ramirez, who is also a nurse, saw in the E.R. at another facility an awful example of what can happen when patients cannot be fully understood.

Elda Ramirez, Cizik School of Nursing, UTHealth Houston: I kept seeing this young woman, and I could see that she was curled up in a chair and she was holding her face. And I saw in the chart that she had facial trauma.

And I thought, oh, well they're surely getting some imaging or whatever. And I looked at the chart, and there was no imaging ordered. So I went up to her. And when I actually went up to her and said (Perdóname, ¿qué está pasando?) and she immediately says (quimicas en mis ojos).

She had chemicals that had splashed in her eyes. And, somehow, in the translation that had taken place at triage, that had been completely missed. I'm like, ooh. And then we were able to move forward. Luckily, she was OK, and we were able to take care of that. But that moment of time where that was missed in translation, that was huge. It was huge.

William Brangham: When there's no nurse or doctor who speaks a patient's language, the job falls to interpreters, like here with this patient who's recovering from a stroke in the ICU at Houston Methodist Hospital.

Erin Mulpur oversees translation services at Houston Methodist. She says it's more than just language fluency. interpreters also need some medical fluency.

Erin Mulpur, Houston Methodist Hospital: They have to be certified. So, there is medical terminology certification that goes along with that to make sure that patients are receiving accurate language interpretation.

William Brangham: So that if I say insulin or I say mastectomy or all the terminology is…

Erin Mulpur: Right. Right. Right.

William Brangham: The hospital has in-person interpreters who speak Spanish, Mandarin and Arabic.

Erin Mulpur: We also provide video remote interpretation.

William Brangham: So that person who might be doing the translation could be anywhere, basically, someone you have contracted with.

Erin Mulpur: Mm-hmm.

William Brangham: But even though technology helps, it raises new hurdles and new questions. What if a patient just wants to go to the bathroom or to call a family member?

Allison Squires: Do you call an interpreter every time someone needs to communicate that type of need? How can we effectively address those types of situations?

William Brangham: Nurses say literal translation is not the only goal.

Erica Yu: And, sometimes, especially with the aging population, that they may not be able to trust nurses when you don't understand their culture. So, I think language, a lot of times, comes with the culture.

William Brangham: Back at La Clinica, Melissa Marinelarena says there's no real substitute for a direct personal connection.

What do you say to the devil's advocate who would just say, ah, Google Translate does all this for you?

Melissa Marinelarena: Google translates, but it doesn't interpret. Those are two very different things. There's nuances to when somebody says something, when they speak. It's understanding how someone grew up.

And, again, it's more than what somebody is saying. And I think it's hard. You can't teach somebody to be called bicultural, right? Like, that's how you grow up.

William Brangham: And you really do think that matters in the end.

Melissa Marinelarena: I do. I think it makes a big difference.

Man: She's going to help me understand you better.

William Brangham: There isn't good research comparing outcomes with in-person native speakers versus interpreters, but there's no question patients appreciate talking to someone who truly understands them.

For the "PBS NewsHour," I'm William Brangham in Washington, D.C.


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