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Last Updated: Jan 3rd, 2005 - 23:26:42 |
Providing Linguistically and Culturally Appropriate Health Care Services
By Gayle Tang, Director, National Linguistic & Cultural Programs
Jan 3, 2005, 22:44
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Published in JCAHO Benchmark – October 2001, Volume 3, Issue 10
The United States is already one of the most diverse societies in the world, and it is becoming increasingly multicultural and multilingual. Immigrant, refugee and limited-and non-English proficient (LEP/NEP) populations continue to grow. According to the 1990 U.S. Census, 31.8 million residents were non-English speaking. The most common language spoken by non-English speakers is Spanish (17.3 million) with a significant number speaking Asian, African, and other European languages and dialects. Racial and ethnic groups are expected to reach 40 percent of the population by 2030.
As a result, providing linguistically and culturally appropriate health care services is becoming increasingly complex. The challenge facing health care organizations now is how to ensure quality care and services to these diverse patient populations, especially the LEP/NEP population.
At Kaiser Permanente many of us believe it is our responsibility to protect a patient's right to receive the information necessary to make informed health care decisions, this includes the LEP/NEP patients. Language is at the heart of human interaction and communication. Effective communication is crucial to the delivery of culturally competent health care. When a health care provider and patient do not share the same language, communication is restricted.
As a way to systematically facilitate understanding and communication among people of different cultures speaking different languages in a health care setting, we developed the Multicultural Services Department at Kaiser Permanente's San Francisco Medical Center. Since 1996, our department has been providing interpretation services, translation services, cross-cultural publications, and education and training throughout the medical center. Multicultural Services also works with Health Plan departments to translate and produce signage, communication materials, and health education and facility information in other languages when needed. In 2000, the Multicultural Services Department provided language services in 42 languages and dialects. Among the largest groups, the department serves approximately 13,000 Kaiser Permanente members who speak Chinese dialects and 7,000 members who speak Spanish.
A survey of U.S. public and private teaching hospitals, conducted by the National Public Health and Hospital Institute, showed that more than 11% of patients in responding institutions required interpreter services. One-third of the institutions reported that, on average, 27% of their patients require interpreter services. These statistics illustrate that effective communication is crucial to the delivery of culturally competent health care.
Although much has been accomplished, we still face obstacles in the lack of community standards. When it comes to teaching health care interpreting, not every state has standards of practice and a code of ethics. There are some general agreements, but since there are many variables with all the different languages and cultures, the debates are still going strong. Presently, we are working with the California Health Interpreter Association (CHIA) on establishing standards for California. National standards are also being developed.
A health care interpreter like other health professionals requires training. A well-trained interpreter should be expected to act as a conduit, a clarifier, a cultural broker, and an advocate for the patient. To facilitate effective communication, an interpreter must be skilled at breaking through both cultural and language barriers among the health care provider, the patient and his or her family at the very instant the barriers arise. Each of the interpreter's roles is combined with a set of techniques and responsibilities, such as maintaining transparent communication which involves making sure that every single person participating in a conversation knows exactly what all the other persons are saying every single moment.
An interpreter often communicates sensitive information and is expected to maintain a patient's confidentiality. In one case, a patient was assigned an interpreter who spoke the wrong Chinese dialect. The patient became uncontrollably angry because the request for the wrong interpreter had come from her abusive husband who made the request intentionally to harm her. The patient asked that no one ever speak to her husband again.
An interpreter's default role is that of a conduit; that is, he or she interprets everything that is said, how it is said without omitting, adding or polishing. However, communication in health care often presents interpreters with instances that require switching extemporaneously to any of the other roles and then reverting back.
Here's an example of how an interpreter becomes a clarifier. Traditional Chinese women find it extremely embarrassing to talk about their more private body parts. So, instead of saying "breasts," for example, they might say "chest" which in Chinese can mean either "chest" or "breasts." Thus, confusion results when a provider thinks the patient is talking about a chest X-ray, while in effect she is talking about a mammogram. To avoid the confusion, the interpreter could clarify with the patient, when the term first comes up by asking if she is referring to her breasts. By doing so, the interpreter also saves the patient from the embarrassment since she would probably have to answer yes or no.
When a provider lacks the knowledge of cultural nuances that can affect the quality of care, an interpreter should know how and when to intervene and explain the cultural framework. But, he or she must confirm with the patient that there is in effect a cultural issue. In other words, the interpreter must never make assumptions about a patient's culture, even if the interpreter belongs to the same culture as the patient.
For example, after confirming the beliefs of a new Cambodian father who is happily asked to enter labor and delivery to cut the umbilical cord of his newborn baby, the interpreter can explain that, in the father's cultural reality, he would suffer greatly by entering and participating in the delivery. Unbeknownst to the providers, who think of this as a joyous moment for the father to bond with the baby, Cambodian men are not allowed to see the color red (blood) for it brings bad luck to them, their family and possessions.
The interpreter should also be prepared to advocate for the patient who may not know he has the right to refuse if what he is being asked to go against his cultural beliefs. LEP/NEP patients do not always know or understand the law since most of the time, the law is written in English. In the case of the Cambodian father, he may assume that cutting his baby's umbilical cord is required by law.
When we first started Multicultural Services, we also sought ways in which to train our staff to provide language and cultural interpretation for our patients. As a result in 1996, we partnered with the Health Science Department at City College of San Francisco (CCSF) to assist in the design and implementation of a health care interpreter certificate program. This effort grew into a large and formal education program currently in place, and being disseminated throughout California. In July, instructors from six community colleges convened for a Health Care Interpreter Instructor Training Summer Institute in San Francisco, during which they learned about the certificate program curriculum.
The Health Care Interpreter Certificate Program is a cost-effective approach to meeting the challenge of providing services to a multicultural and multilingual patient population. The program's goal is to increase the pool of competent interpreters and to meet the needs of our diverse community.
Health care providers who speak a little of a patient’s language may choose not to use an interpreter for the sake of convenience or perhaps they strongly believe that the ideal communication should occur between the provider and patient, and not through an interpreter. Others may feel compelled to use unreliable and ethically suspect means, such as requesting a bilingual housekeeper, or asking the patient's family member to interpret for them. There could be tragic outcomes resulting from misinformation, not to mention the possibility of legal liability.
Not long ago, an elderly Chinese woman was admitted for a stroke. After her completely non-responsive condition was assessed, she was pronounced brain dead. When the family asked to see the patient, a family member asked her a question in her language, and she responded.
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