Communicating with limited english proficiency persons: Implications for nursing practice

Communicating with Limited English Proficiency Persons: Implications for Nursing Practice Antonia M. Villarruel, RN, PhD, FAAN C a r m e n J. Portillo, RN, PhD, FAAN P a m e l a Kane, BSN, R N

Demographic changes, federal law, state and local regulations, and the potential for legal liability are important reasons for nurses and other health care providers to incorporate appropriate strategies for communicating with limited English proficient patients. Strategies commonly employed for addressing language barriers in health care settings are presented. The advantages, disadvantages, and implications of these approaches for nursing practice are discussed. USE OF INTERPRETERS IN NURSING PRACTICE ultural competence is the capacity to function effectively in cross-cultural situations.1 Language is an important component of culturally competent care. It is the foundation for nursepatient relationships and serves as the medium for interpersonal and cross-cultural communication. Language is essential for obtaining an accurate and comprehensive patient and family assessment, formulating and implementing a treatment plan, determining the efficacy and acceptability of nursing care, and evaluating associated outcomes. Differences in language between nurse and patient make clear and accurate communication difficult to achieve. The nurse-patient relation is attenuated and nursing care, patient outcomes, and patient satisfaction suffer. As a result of demographic changes in the United States, nurses are increasingly faced with the challenge of communicating with limited English proficiency (LEP) persons. To communicate effectively with patients who speak limited English, nurses must be aware of the different options for addressing language differences and the professional, legal, and

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Antonia M. Villarruel is an assistant professor at the University of Pennsylvania, Philadelphia. Carmen J. Portillo is an associate professor at the University of California San Francisco. Pamela Kane is a graduate midwifery student at the University of Pennsylvania, Philadelphia. This article was made possible by a grant from the National Coalition of Hispanic Health and Human Services Organizations as part of a cooperative agreement from the Health Resources and Services Administration of the US Department of Health and Human Services. Nurs Outlook 1999;47:262-70. Copyright © 1999 by Mosby, Inc. 0029-6554/99/$8.00 + 0

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ethical implications each approach has for nursing practice. The purpose of this article is to provide direction for nursing practice when caring for LEP persons. SIGNIFICANCE It is particularly difficult to develop guidelines that validate the importance of providing quality care for LEP persons within the current climate of anti-immigrant legislation and English-only initiatives. However, the large number of LEP persons in the United States compels nurses to address this issue. According to the US Census Bureau, 14% of the nation's population speak a language other than English in their home. This percentage is greater than 40% in major cities such as New York City, Los Angeles, Miami, Honolulu, Newark, NJ, and El Paso, Tex. 2 More than 31.8 million US residents speak a language other than English in their homes, with more than 13.9 million reporting that they speak English less than "very well. ''3 With 50 primary languages represented in this number, Spanish speakers are the majority of non-English speakers as well as those who speak English less than "very well." According to the Census Bureau, 4 17.3 million (54%) of all non-English speakers in the United States speak Spanish in the home, and 8.3 million report that they speak English less than "very well." Persons who speak Chinese rank second (0.7 million) among persons who speak English less than "very well." Thus LEP persons represent a significant portion of the population. Title VI of the Civil Rights Act of 19645 offers certain legal protections for LEP patients. Specifically the act states that:

...no person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination in any program receiving federal funds. Virtually all health care and human service institutions receive federal financial assistance such as Medicare, Medicaid, or Hill-Burton funds and t h u s are subject to Title VI mandates. Health care institutions receiving federal financial assistance are prohibited from adopting policies and procedures that exclude or limit access of LEP persons to health care institutions. The Department of Health and Human Services mandates that reasonable steps be taken to provide services and information in languages other than English to ensure that LEP persons are informed and can effectively participate and benefit from programs. 6 VOLUME47 • NUMBER6 NURSING OUTLOOK

Communica~ngwith LimitedEn lishProficiencyPe~ons"ImpHca~onsfor Nu~in PracHce The Office for Civil Rights (OCR) enforces Title VI after the filing of a consumer complaint. In some instances, the O C R has required hospitals to provide interpreters and translate written notices in locations where there is a sizable population of LEP persons. However, O C R decisions have provided little guidance in defining the level or quality of interpreter services. 7 Thus, although there cxists a legal basis that establishes the right of LEP persons to quality health care, the implementation and monitoring of the law have not been adequate.

Language is essential for obtaining an accurate and comprehensive patient }¢ndfamily assessment, formulating and implementing a treatment plan, determining the efficacy and acceptability of nursing care, and evaluating associated outcomes. ill

Accreditation standards for health care organizations also reflect the intent of the O C R and the needs of LEP persons. For example, standards of the Joint Commission on Accreditation of Healthcare Organizations require that health care institutions "respect and foster their [patients and families] sense of civil rights." They further require that services "promote patient and family involvement in all aspects of their care. ''8 Specifically included are standards that require health care institutions to develop a formal process to guide and support the availability of translation services. The growth of managed care and competition among health care plans for members has focused greater attention on the provision of health services to LEP persons. In efforts to "capture lives," managed care organizations have targeted LEP persons seeking to demonstrate their capacity to deliver a comprehensive range of bilingual or interpreter services. For Medicaid populations, state requirements for managed care contracts provide an opportunity for improved language services. Several states have naandated managed care contracts to include the (1) identification of bilingual providers in health care networks, (2) demonstration of bilingual and interpreter capacity of the managed care network, and (3) provision of enrollment information in the language of the targeted population. In summary, demographic changes, federal law, state and local regulations, accreditation standards for health care organizations, and the potential for legal liability are important reasons for nurses to incorporate in their practice appropriate strategies for communicating with LEP patients.

COMMUNICATING WITH LEP PERSONS LEP persons face the potential of poor communication with their health insurance plan and health care practitioner and, therefore, may be unable to access adequate services, which can subsequently escalate the cost of care if access is delayed, denied, or the patient's symptoms and treatment plan are inadequately communicated. Several options exist for addressing language barriers in health care settings staffed by monolingual

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English-speaking providers. Health care facilities typically use a combination of strategies, depending on the nature and timing of the desired communication, interpreter availability, language mix of the patient population served, and cost. 9-12 It is important to recognize that not all strategies are adequate. In this section, the strategies commonly used are presented along with a discussion of the advantages, disadvantages, and implications for nursing practice Ohble 1).

"GETTING BY" Nurses and other health care professionals often use gestures, facial expressions, a change in voice volume, or the use of a few key words or phrases in the target language to "get by" when communicating with LEP persons. 9,1° For example, nurses may elicit information regarding a patient's pain by pointing to an area of the body, making grimaces as if in pain, or by use of the word for "pain" in the target language. Nurses may use gestures to demonstrate the cleansing of the urogenital area for a clean catch urine sample. It is the rare obstetric nurse who cannot tell Spanish-speaking patients in labor to "puja, puja" (push). This method of communicating with limited English speaking patients enables the care provider to communicate with the patient immediately without having to wait for an interpreter. This method may be effective when basic or uncomplicated information is exchanged. It is often used in emergency situations or in the absence of anyone who speaks the patient's language. However, there are significant disadvantages associated with this method. The amount and complexity of information exchanged in this manner is extremely limited. 7 The potential for miscommunication is high. Inadequate and limited information jeopardizes the quality of care. For example, a nurse tried to use this method to communicate to a mother that a prescribed antibiotic elixir was for her son's ear infection. The mother returned to the emergency department 3 days later. The ear infection had not resolved, and the outer ear was encrusted with a pink film. The mother, thinking she was following instructions from the nurse had in fact instilled the elixir directly into her son's ear. Nurses may use this method of communication in situations in which it is not appropriate because of the perceived inconvenience of use of other methods of interpretation. They may also have an inaccurate perception of their ability to "get by" in the target language. 1° AD HOC INTERPRETERS It is also common for nurses and other health care providers to use any available bilingual person as an interpreter when communicating with LEP patients. Most ad hoc interpreters are family members or friends of the patient. However, there have been cases reported in which persons in the waiting room or staff fiom nearby ethnic restaurants have been used as interpreters. 9,1° Advantages of this method include the ready availability of an interpreter because family members or friends often accompany the patient. Family and friends also serve as sources of patient and cultural information because they are likely to know the patient and generally share a similar sociocultural background. Their presence may help set the patient at ease. 263

Communicating with Limited English ProficiencyPersons:Implicationsfor Nursing Practice However, the use of family members or friends as interpreters compromises patient privacy and thus affects the quality of care. The patient's family and friends may lack the ability to speak and understand English well or understand health care terminology and procedures. Family and friends lack training as interpreters. They are likely to commit errors involving omission or addition of information, substitution of terms, incorrect numbers and names, interpretation of patient concerns, condensation, and role exchange. 12-14As an example of omission, condensation, and interpretation of events, a young woman comes into the emergency department and provides a long and detailed account of an acute episode of flank pain, nausea, and vomiting that evening. A friend who accompanies her and is acting as an interpreter simply reports to the health care provider "She has back pain...but she's always complaining about that. She threw up too, but it could be the flu. Her husband was sick last week with the same thing." Thus an acute episode of kidney stones could be interpreted as a condition of less importance. Health care providers and administrators often perceive the use of family and friends as interpreters as cost effective compared with other methods of translation. A search of the literature yielded no study of health care outcomes associated with the use of family and friends as health care interpreters. Further, strong anecdotal evidence suggests patient care and level of satisfaction are negatively affected by using this method. 9,12,14 Thus the costs associated with negative health care outcomes, suboptimal care, inadequate follow-up, and potential litigation may outweigh the cost savings from the use of family or friends as interpreters. It is important to consider that family and friends are not bound by any code of conduct. They may interpret, editorialize, or deliberately withhold information they perceive as embarrassing or upsetting from either the patient or health care provider. They may also fail to keep patient information confidential. Certain situations such as those involving family violence and abuse or associated with social stigma such as mental illness, abortion, and sexually transmitted diseases pose potential limitations. Patients may be reluctant to disclose important information when a family member or friend is used as an interpreter. These situations increase the likelihood that nurses and other providers will fail to obtain crucial information needed to evaluate and treat the patient. Finally, health care providers should refrain from use of minor children as interpreters. The child's developmental level and associated linguistic limitations, exposure to inappropriate information, the likelihood of misinterpreting complex information, and the potential for disrupting the balance of power within the family dictate that use of children as interpreters be avoided. 7 The use of minor children as interpreters is a clear example of role exchange--the child becomes the adult in this situation, and the parent is forced inappropriately to rely on the child for help and support.

VOLUNTEER INTERPRETERS Some health care institutions maintain formal and informal lists of bilingual staff and community members willing to 264

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volunteer as interpreters for limited English-speaking patients. 10 Advantages of use of voltmteer interpreters include low initial costs and the likelihood that the interpreter wilt be familiar with health-related terminology and procedures. Some institutions screen volunteer interpreters for language skills and health knowledge. In many cases, institutions require volunteer interpreters to sign statements of confidentiality, particularly if they are not employed by the facility in another capacity. Use of volunteer interpreters instead of family or friends enables patients to maintain their privacy and to control the nature and amount of information shared with family members and friends.

Health care providers should refrain jqom use of minor children as interpreters. However, not all health care facilities that use volunteer interpreter banks require interpreters to demonstrate basic qualifications or abilities necessary to perform interpreter services. In most instances, volunteer interpreters rarely receive training in interpreting and may commit significant errors in translation or violations of patient confidentiality. The lack of training and resulting errors compromise the quality of health care and increase the likelihood of negative health outcomes. 9,12,14 The availability of volunteer interpreters is of significant concern, particularly in emergency situations or outside normal business hours. It is extremely difficult for an institution to require and maintain a high level of reliability and commitment from either in-house or outside volunteer interpreters. Work obligations often limit the availability of inhouse volunteer interpreters. In-house staff used as volunteer interpreters may be unable to fulfill their assigned responsibilities. Other staff may resent the added responsibilities they must assume to enable their co-worker to serve as an interpreter. Few institutions have guidelines for compensating staff for performing interpreting services with additional pay, recognition, or relief from work duties. The educational, health care, and language backgrounds of bilingual staff who serve as volunteer interpreters vary widely. For example, although frequently called on as interpreters, janitorial and housekeeping staff generally do not have the requisite interpreting skills or knowledge of health care terminology. Similarl)~ it can not be assumed that professional health care staff possess the range of linguistic skills needed to function adequately as interpreters. 9 For example, a nurse may consider himself or herself bilingual but, in fact, may lack knowledge of appropriate health care terminology in the target language. When bilingual volunteer staff are used, particularly if nursing or medical staff are used as interpreters, there is the potential for staffworking with the patient to abdicate responsibility for the content of the communication. For example, a nurse volunteer interpreter might be simply asked to "review discharge instructions" with a patient or family, which is inappropriate, because it cannot be assumed that the interpreter is sufficiently familiar with the patient or his or her condition to VOLUME47 • NUMBER6 NURSING OUTLOOK

Co~un!caq{,go witt~ LimitedoEnglishoProfic{~fyo Persons[Implications for "Nursing Practice . . . . . . . . . . . . .

Interpreting options for communicating with LEP patients "Getting by"

Advantages Allows for immediate communication in absence of interpreter May be adequate for exchange of limited amount of basic information

Disadvantages Inadequate for exchange or complex and lengthy information High potential for miscommunication Perceived convenience may be a disincentive to pursuing other interpreter options

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Implications for nursing practice Assess the accuracy of information exchanged by reasking questions in a different way; having patient restate/demonstrate information; be attentive to verbal cues Advocate for use of a qualified interpreter if the situation requires more than the minimal level of communication Establish clear expectations for the interpreter before beginning

Ad Hoc interpreters

Assess the accuracy ofinformation exchanged

Ready availability

Patient's privacy is not protected

Source of patient and cultural information

Interpreter's ability to speak and understand English may be limited

Be alert for situations in which information may be filtered

Interpreting skills or training may be limited

Advocate for use of a qualified interpreter ifnecessary

Limited interpreter understanding of health care terminology

Never use children as interpreters

Patient may feel more at ease Low up-front costs

Potential for interpreter to filter information Interpreter not bound by code of conduct Patient care and level of satisfaction negatively affected Volunteer

Likelihood of prior interpreting experience in health care setting

Training and evaluation of volunteer interpreter often not addressed

Low up-front costs

Extreme variability in quality of interpreting

Capability if screening interpreters for linguistic and interpreting ability Patient privacy and confidentiality more likely to be protected

Interpreter availability limited Demands of interpreting reduce time for staff volunteers to complete work duties Compensation of in-house staff" for interpreting rarely considered Health care staff may abdicate responsibility for content of information, especially when nursing or medical staff serve as interpreters

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Become aware of institution's practices regarding screening, evaluation, and training of volunteer interpreters Assess the accuracy of information exchanged Never abdicate responsibility for content of communication Advocate for use of a qualified interpreter if necessary

Continued 265

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communicating with LEP patients Bilingual staff interpreters

Advantages Improved interpreter availability

ViUarruel, Portillo, and Kane

hnplications for nursing practice

Disadvantages Potential lack of institutional training, evaluation, and monitoring

Lower cost than frequent use of contracted professional interpreters/ language line services

Interpreter needs for smaller language groups may not be met

Become aware of institution's practices regarding screening, evaluation, monitoring, and training of bilingual staff interpreters

Opportunity to train and evaluate bilingual staff interpreters

Variation in quality of interpreting skills

Assess the accuracy of information exchanged

Greater familiarity with health care terminology

Advocate for use of qualified interpreter

Interpreters adhere to code of conduct Professional interpreters

High level of interpreting expertise

Costly

Assess the accuracy of interpretation

Wide range of languages through outside interpreter agencies

No standard criteria for "professional" interpreters

Adherence to code of professional conduct

Limited availability outside normal business hours

Obtain information about contracting agency's practices regarding screening and evaluation of professional interpreters

Some are covered by liability insurance Cultural mediators

Improved ability to assess and meet patient needs at multiple levels

Limited number of language groups are covered

Participate actively in the planning and implementation of interpreter cultural mediator programs

Significant commitment required for development and implementation of program

Participate in planning how to meet the needs of other language groups not covered by the program Learn to function as part of a health care team that includes interpreter cultural mediators

Language line services

High quality of interpretation

Can be costly

Wide range of languages covered

Interpreter is unable to use visual

Explain to patients how the language line works Assist in facilitating the interpreted encounter

cues

Rapid access to interpreter Formal screening, evaluation, and training of interpreters

Rapport among patient, provider, and interpreter more difficult to achieve

Interpreters adhere to code of ethics

Communication may be awkward

Interpreters likely to be covered by liability insurance

Unavailability of phone jacks in certain areas

Assess the accuracy of information exchanged Advocate for the use of portable conference phones if language line services are used frequently Advocate for the establishment of a language line account that can be accessed in emergency situations

Other technologies

May offer easy~ rapid access to interpreting services

Not widdy available

Monitor developments in interpreting technologies

Limited field testing May increase access to high-quality interpreting services

Participate in the piloting of alternative technologies when appropriate

Equipment may be costly hnprovement in quality of interpretation or access to interpreter services not established

Advocate for the use of trained interpreters in conjunction with other technologies

Must be used in conjunction with expert interpreters

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Commun!cating, with Limited English Profic{en~ Persons~l~p !icationsoforoNursingoPract~'ce. . . . . . . . . . . . . . . . . . . . . . . communicate all the necessary information. When health care professionals are used as volunteer interpreters, it is important to delineate and assign appropriately the separate roles of patient care, professional responsibility, and interpreting.

When health care professionals are used as volunteer * ime~prete~, ~t is important to delineate and assign appropriately the separate roles of patient care, professional respondbility, and interpreting. BILINGUAL STAFF INTERPRETERS Health care facilities that serve large numbers of LEP patients may choose to hire bilingual staff interpreters. I° Interpreter availability, at least for the languages spoken by bilingual staff interpreters, is greatly improved, although coverage outside of normal business hours may still be limited. Bilingual staff interpreters may cost the institution less than frequent use of contracted professional interpreters or telephone language lines. Ideally, bilingual staff interpreters possess specific training and experience in medical interpretation and are bound by a code of conduct that ensures protection of patients' confidentiality, accuracy and completeness of interpretation, and impartiality. The use of bilingual staff interpreters provides health care institutions with the opportunity to establish and monitor the quality of interpretation services. Efforts to achieve and maintain quality include ongoing training and professional development and direct evaluation of individual interpreters. However, bilingual staff members are generally not able to meet all the language needs of health care facilities, because they are typically hired for only the major language groups of the patient population served. The level of interpreting skill and quality of interpreting also varies considerably among bilingual staff interpreters.

PROFESSIONAL INTERPRETERS The label "professional" as applied to health care interpreters is loosely defined, because there are currently no nationwide standards of practice. However, several states, including Washington and Massachusetts, have implemented testing and certification of social service interpreters and practice standards for medical interpreters. 15,16 Many professional health care interpreters possess a high level of knowledge and expertise. Some hold advanced degrees in languages or in interpreting and translation. Professional interpreter services are usually contracted for directly with the interpreter or with an outside interpreter agency. Some institutions also hire professional interpreters as part-time or full-time staff. Although qualifications and quality vary considerably among "professional" interpreters, the caliber of their services is generally higher than that of ad hoc, volunteer, or bilingual staff interpreters. Professional interpreters are reliable and are typically bound by a code of conduct. Some carry liability insurance to cover damages

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resulting from interpreting errors. Professional interpreting services are costly, commonly ranging from $50 an hour to more than $100 an hour. They also may not be available at night or on the weekend or at short notice in an emergency.

CULTURAL MEDIATORS A small number of health care institutions that serve a large number of immigrant and refugee populations have devdoped a model of interpretation in which the interpreter also acts as a cultural mediator or broker.17 In nearly all cases, the interpreter shares the same cultural background as the target community. Cultural mediators are a part of the health care team and work closely with medical and nursing staff. Along with medical interpreting, the cultural mediator interprets the cultural and social circumstances that may affect care, which enables providers to gain a more comprehensive understanding of patient needs and to negotiate culturally appropriate plans of care. Community House Calls Program at the Harborview Medical Center in Seattle, Wash, offers one example of this type of model. 17 The use of cultural brokers for addressing language barriers requires a significant commitment from health care institutions. Comprehensive plans for hiring, training, and evaluation of interpreter cultural mediators is required. 18 The cultural mediation model also involves provider training in crosscultural health care, interpreted health care encounters, and patients' cultural background. It is generally not feasible for an institution to have interpreter cultural mediators on staff for all the languages and cultures represented among its patients.

Along with medical interpreting, the cultural mediator interprets the cultural and social circumstances that may affect care, which enables providers to gain a more comprehensive understanding of patient needs and to negotiate culturally appropriate plans of care. TELEPHONE LANGUAGE LINES Interpreting services are also provided on telephone language lines. The nurse or other health care provider and the patient are generally face to face, while an off-site interpreter communicates through a speaker or hand-held phone. The health care facility must first establish an account with the language line. An institutional code is then provided for staff members' access. To use an interpreter, staff members dial a toll free number, request an interpreter for the language needed, and are connected with the interpreter, usually in less than a minute. Some health care institutions have acquired relatively inexpensive portable conferencing phones specifically designed for language line interpreting services to facilitate communication among the 3 parties. Telephone language lines such as AT&T Language Line Services and Pacific Interpreters, Inc, can provide access to interpreters in more than 140 languages 24 hours a day, 7 days a week. Language line interpreters receive training in medical 267

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Diversity Rx contains information regarding the basics of linguistic and cultural competence; models of interpreter practice; legislation, case law, and policies relating to the provision of health care to LEP patients; and links to other organizations and Web sites. Address: http.'//www.diversityrx.org/HTML/DIVRX htm. Ethnomed offers detailed cultural profiles, including health care practices and beliefs, of 7 language groups from Africa and Southeast Asia; patient education materials in a variety of languages; scholarly information regarding selected cross-cultural health care issues; the Community House Calls program, including the manual Beyond Medical Interpretation: The Role of Interpreter Cultural Mediators; research in cross-cultural health care; and links to related Web sites. Address: ht~o://www.hslib.washington.edu/clinical/e~hnomed/hchc.html. The Cross Cultural Health Care Program provides information about interpreter trainings, interpreter forums, and community building. Address: http:/Ipw2.netcom.com/~xculture/index.html. The Center for Cross Cultural Health offers information about cross-cultural health care; resources for cultural competency in health care; the center's newsletter; community profiles; and events and conferences. Address: ht~p.'//www,umn.edu/ccch/index.html. The Office for Civil Rights, Department of Health and Human Servicesprovides information about Title VI as it relates to health care. Rights, responsibilities, and how to file a complaint are some of the information included. Address: hup://www.os.dhhs.gov.'80/progorg/ocr/newfreq/html. The Office of Minority and Women's Health, Health Resources and ServiceAdministration, Department of Health and Human Services defines and describes culturally competent programs. Address: http..//i58. 72.105. I63/cc/default.htm.

interpreting and are tested for linguistic competency and knowledge of medical terminology. They also sign a code of ethics that sets standards for confidentiality, accuracy and completeness of interpretation, impartiality, conflict of interest, accreditation, personal courtesy, and professional development. Typically language line interpreters are covered by liability insurance. Quality specialists conduct random monitoring of interpreters, who are evaluated at designated intervals by using specific quality standards. Contractual arrangements and costs for language line services vary. Institutions may pay a monthly fee plus a perminute rate, or just a per-minute rate. The cost of language line services ranges between $2 and $7 per minute along with any monthly membership or subscription fees. Some experts argue that telephone interpreting is appropriate only for exchanging basic information. The language line interpreter is likely to miss the nuances of body language and facial expression, and is forced to depend solely on the content and tone of the conversation. 19 Interpretation involving frequent references to visually identified objects, such as patient teaching by using demonstration-redemonstration, may also present difficulties for language line interpreters (E. McDonough, Massachusetts Medical Interpreter, personal communication, 1998).

VIDEO TELECONFERENCING AND OTHER TECHNOLOGIES Video Teleconferencing Video teleconferencing avoids some of the limitations of language line services. Skilled interpreters located off-site provide interpreting services for parties who are face to face with the use of specialized computer software, a video recorder, and telephone or Integrated Services Digital Network (ISDN) lines. Video teleconferencing allows the interpreter to observe the provider268

patient interaction and use visual cues such as body language and facial expressions. Results from an unpublished pilot study indicated a high level of satisfaction among health care providers, patients, and interpreters regarding the ease and quality of video teleconferencing for interpreter encounters (M. Rynearson, personal communication, April 1998). Although the cost of video and computer equipment is relatively affordable, current technology for ISDN lines is expensive. The quality of video transmission via telephone lines for interpreting is inadequate for interpreting. Further, the cost of installing ISDN lines in multiple rooms within a health care facility is prohibitive. In addition to investing in video teleconferencing technology, health care institutions must still pay for the interpreter services used. Currently, there is only limited and anecdotal evidence of additional benefits of interpretation by video teleconferencing versus language line services. Advocates of video teleconferencing indicate that it may offer important advantages over telephone interpreting once the technology becomes more affordable.

Remote Simultaneous Interpretation Remote simultaneous interpretation is common in diplomacy and international business, but it is not used widely in health care. The provider and patient are face to face. However the interpreter, patient, and provider use earphones and microphones that are electronically linked with each other, allowing the interpreter to communicate information simultaneously into the target language. The individual receiving the interpreted communication hears the message through the earphones virtually as it is being delivered. The earphones also serve to muffle much of the sound of the other party's voice. The interpreter is on-site, but often not visible to the provider and patient. Remote simultaneous interpretation offers several advantages. One study documented an increase in words spoken VOLUME47 • NUMBER6 NURSING OUTLOOK

Communicatingwith LimitedEnglish ProficiencyPersons:Implicationsfor NursingPractice between providers and interpreting errors by using remote simultaneous interpretation. 2° This method holds the potential for decreasing the length of interpreted encounters thereby reducing costs. It may also facilitate a more direct rapport between providers and patients because it most closely replicates the dynamics of an exchange between persons speaking the same language. Current technology limits the benefits of remote simultaneous interpretation. Because interpreters must be on the premises, availability of interpreters is a limiting factor. Furthermore, remote simultaneous interpretation generally requires a high level of training and skill, which many interpreters, including those in health settings, do not possess.

Nurses should advocate for the use of rigorously screened interpreters who adhere to a code of conduct that protects the patient and who are subject to quality monitoring.

Other Technologies The use of specialized computer software can also assist health care providers in communicating with LEP patients. Currently these technologies are most useful as an adjunct to patient teaching and least useful in situations requiring open-ended questions (J. Esler, personal communication, May 1998). One advantage of this type of technologic innovation is the ability to combine audio and visual information to offset the difficulty patients with visual deficits or low literacy levels experience when reading. However, in most situations, this type of technology cannot replace a qualified interpreter.

IMPLICATIONS FOR NURSING PRACTICE The use of interpreter services is an important adjunct in the care of LEP patients. Interpreter services are meant to compliment, but do not replace, the responsibilities of nurses and other health care providers in assessing, communicating with, and caring for LEP patients. Health care providers should be aware of institutional policies and resources regarding the care of LEP patients and also recognize the limitations of available interpreter options. A review of these policies should, at minimum, be included in any orientation to the facilities. Nurses should be committed to ensuring the quality of nursing care and provider-patient interaction when interpreters are used. (See Box I for additional resources on interpreting and interpreter services). As advocates for LEP patients and to promote the safety of professional nursing practice, efforts at many levels are needed to ensure the availability of adequate interpreter support in health care institutions. When working with LEP patients, nurses must first assess the nature and purpose of the communication they plan to have with the patient. They can then determine the mode, or modes, of interpreting appropriate for the encounter. Awareness of institutional policies and resources before encounters with LEP patients can reduce the tendency to settle

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for "getting by." Nurses should then match the communication with the most appropriate interpreting strategy available to them. Nurses should be aware of the skill level and training of volunteers and staff" who function as interpreters. Information regarding the screening and evaluation of interpreters should be provided to nursing staff by the institution. in many instances, the best available interpreting options will still be inadequate to meet the patient's needs. Documentation of these situations is an important asset in protecting nursing practice and in advocating for adequate interpreter support. As advocates for patient care, nurses should be actively involved in evaluating the quality of interactions with LEP patients and the use of interpreters. Information and evaluation provided by nurses are important as administrators estimate and evaluate the costs and outcomes of interpreting options for the institution and population being served. 11 When volunteers, bilingual staff, professional interpreters, or language line interpreters are used, nurses should be aware of the procedures their institutions use to screen and evaluate interpreters. They should be aware of the code of interpreter conduct and the nature and extent of measures used to ensure the quality of interpretation. Nurses should advocate for the use of rigorously screened interpreters who adhere to a code of conduct that protects the patient and who are subject to quality monitoring. Because of the frequency of patient and interpreter interaction, nurses should be involved in the design of interpreter training. Nurses should also request in-service training in how to work with interpreters. 13,21,22 In summary, the care of LEP persons presents special challenges to nurses and other health care providers. Nurses have a professional, legal, and ethical obligation to ensure that appropriate language services are used when communicating with LEP patients. The use of qualified interpreters can facilitate the delivery of culturally competent and quality care to this growing population. Thanks to Douglas N. Kane for his comments on an earlier version of this article. • REFERENCES 1. CrossTL, BazronBJ, Denies K, et al. Towardsa culturallycompetent systemof care. Vol 1. Washington(De): NationalInstitute of Mental Health, Child and AdolescentServiceSystemProgram; 1989. 2. US Bureau of the Census. Detailed language spoken at home and ability to speak Englishfor persons 5 yearsand above, United States 1990. Washington (DC): US Bureau of the Census; 1990. 3. US Bureau of the Census. Hispanic Americans today. Current population reports, P23-183. Washington (DC): US Government Printing Office; 1993. 4. US Bureau of the Census. Population projections of the United States, by age, sex, race and Hispanic origin: 1995 to 2050. Current population reports, P25-1130. Washington (DC): US Government Printing Office; 1996. 5. Civil Rights Act, 42 USC Section 2000 (d) (1964). 6. Department of Health and Human Services, Office *br Civil Rights. Guidance memorandum. Title VI prohibition against national origin discrimination--persons with limited-English proficiency.Washington (DC): DHHS, OCR; 1998. 7. Woloshin S, Bickell N, Schwartz L, Gany F, Welch G. Language barriers in medicine in the United States. JAMA 1995;273:724-8. 269

Communicating with Limited English ProficiencyPersons:Implicationsfor Nursing Practice 8. Joint Commission on Accreditation of Healthcare Organizations. November update CAMH. Overbrook Terrace (IL): JCAHO; 1998. p. 1-15. 9. Baker D, Parker R, Williams M, Coates W, Pitkin K. Use and effectiveness of interpreters in an emergency department. JAMA 1996;275:783-8. 10. Ginsberg C, Martin V, Andrulis D, Shaw-Taylor Y, McGregor C. Interpretation and translation services in health care: a survey of US public and private teaching hospitals. A National Public Health and Hospitals Institute (NPPHI) Report. Washington (DC): NPPHI; 1995. 11. Hornberger J. Evaluating the costs of bridging language barriers in health care. J Health Care Poor Underserved 1998;9:$26-$39. 12. Downing B. Quality in interlingual communication and quality of care. Proceedings of the Kaiser Family Foundation Forum on Responding t o Language Barriers to Health Care; 1995; Washington, DC. 13. Putsch R. Cross-cultural communication: the special cases of interpreters in health care. JAMA 1985;254:3344-8. 14. Vasquez C, Javier R. The problem with interpreters: communicating with Spanish-speaking patients. Hosp Community Psychiatry 1991;42:163-5.

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15. Massachusetts Medical Interpreters Association, The Education Development Center. Medical Interpreters standards of practice [draft]. Boston: Massachusetts Medical Interpreters Association, The Education Development Center. 1995. 16. State of Washington, Department of Social and Health Services. Professional Language Certification Examination Manual. State of Washington, Department of Social and Health Services. Olympia (WA); 1995. 17. Community House Calls. Web site: ht~o.'//www.hslib.washington.

edu/clinical/ethnomed/hchc.html; 1997. 18. Musser-Granski J, Carrillo D. The use of bilingual, bicuhural paraprofessionals in mental health services: issues for hiring, training, and supervision. Community Mental Health J 1997;33:51-60. 19. Swaney I. Thoughts on live vs. telephone and video interpretation. Proteus 1997;VI Spring:2. 20. Hornberger J, Gibson C, Wood W, Dequeldre C, Corso I, Palla B, Bloch D. Himinating language barriers for non-English speaking patients. Med Care 1996;34:845-56. 21. Phelan M, Parkman, S. Work with an interpreter. Br Med J 1995; 311:555-7. 22. Poss J, Rangel R. Working effectively with interpreters in the primary care setting. Nurse Practitioner 1995;20(12);43-7.

MISSION STATEMENT Nursing Outlook, the official journal of the American Academy of Nursing, provides critical and timely analyses of emerging professional and health care issues of importance to all nurses. The primarily editorial goals of the Journal are to: 1. Publish innovative, original articles that stimulate thoughtful discussion and scholarly debate and policy implications among nurses and other health care professionals. 2. Inform readers about the diversity of opinion on controversial professional and health care and health policy matters affecting nursing and the health of the public. 3. Provide a multidisciplinary forum for the dissemination of information derived from the synthesis of extant knowledge of current and future clinical practice and health policy alternatives. 4. Disseminate information about creative, alternative, and forward-looking models of education and clinical practice as they relate to changing systems Of health care. 5. Promote the synthesis and use of scientific knowledge in a timely fashion by nurses and other health care professionals to enhance the quality and efficiency of health care. 6. Provide information about leadership and leadership development opportunities for nurses, including professional meetings, hearings, forums, fellowships, and internships. 7. Provide the American Academy of Nursing with a medium for communicating important policy issues and organizational activities. 8. Increase critical awareness of technologies, products, and services that have the potential for increasing the effectiveness of nurses in all settings.

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