Caring for
Limited English Proficient
Patients and Families
Bria Chakofsky-Lewy, RN, MN
bria@uw.edu
April 15, 2015
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JPG
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PNG
King County, Washington, USA,
2010
• 21% of our population identify as foreign born.
• 22% speak a language other than English at home.
• 150 languages are reported to be spoken by children in our public
schools.
COMMUNICATION
is an essential key to being able to provide good health care, in
the ER, to a patient in the hospital, in the clinic, IN THE HOME.
Language congruency
• is usually the best option for good communication.
• TRAIN AND HIRE CAREGIVERS WHO SPEAK THE LANGUAGES
OF THE POPULATIONS YOU SERVE.
• When patients and caregivers don’t
speak the same language, access to
interpreters is necessary in order to
provide safe care.
“The legal foundation for language access lies
in Title VI of the 1964 Civil Rights Act, which
states:
• No person in the United States shall, on the
ground of race, color, or national origin, be
excluded from participation in, be denied the
benefits of, or be subjected to discrimination
under any program or activity receiving
federal financial assistance.”
• Chen A, Youdelman M, Brooks J
• J Gen Intern Med. 2007 Nov; 22(Suppl 2): 362–367.
• Published online 2007 Oct 24. doi: 10.1007/s11606-007-0366-2
Executive Order 13166 and the Office of Civil
Rights Policy Guidance
• “In August 2000, President Clinton drew national attention to
the issue of limited English proficiency when he issued
Executive Order (EO) 13166, Improving Access to Services for
Persons with Limited English Proficiency.9 EO 13166 reiterates
Title VI requirements for federal fund recipients and directs all
federal agencies to ensure that their own programs provide
equal access to LEP individuals. In response to this, OCR issued
an extensive Policy Guidance to assist healthcare providers
and other federal fund recipients in meeting their obligations
to LEP individuals.”
• Chen A, Youdelman M, Brooks J; J Gen Intern Med. 2007 Nov;
22(Suppl 2): 362–367.
Medical interpreters
are fully bilingual individuals who
• have been trained for the role.
• are familiar with medical terminology.
• have passed the Washington state certification
examination and/or a national certification
examination.
• subscribe to a code of ethics.
Family members
• are usually not trained as interpreters.
• have an important role already which can be
compromised when they take the additional role
of interpreter.
• may consciously, or unconsciously, have their
own agenda, rather than adhering to the patient
or caregiver’s agenda.
• Using non-adult children to interpret inverts the
power structure in a family.
Medical interpreters transmit the
meaning of the message from the
speaker to the listener.
In many cases this is not “word for
word.”
In-person interpreter vs. phone
In-person
• Use for initial
assessment, family
conferences, deaf and
hard of hearing patients,
patients who would be
confused by the
telephone.
• Paid by the hour
• Notusually immediately
available
Phone
• Use for intermittent
communication
• Paid by the minute
• Often immediately
available
The pre-conference
• Introduction
• Establish the context, nature, goal of visit.
• Is there cultural information that would be helpful in this
encounter?
The encounter
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Be aware of positioning.
Consider using speaker function on the phone.
Articulate or reinforce confidentiality.
Establish that anything that anyone says will be interpreted.
Speak to the patient, not the interpreter.
Speak in relatively short segments.
Post-conference
• Is there additional cultural information that will help me to
care for this patient?
Avoid
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Medicalese
Jargon
Acronyms
Idiomatic speech
Complicated sentence structure
Changing ideas mid-sentence
Asking more than one question at a time
Remember
• Concepts that can be expressed briefly in English may have no
linguistic equivalent in the target language.
“Cultural competence
• is defined as a set of congruent behaviors,
attitudes, and policies that come together
in a system, agency, or among
professionals and enables that system,
agency, or those professionals to work
effectively in cross-cultural situations. “
• Cross T., Bazron, B., Dennis, K., & Isaacs, M. ( 1989).
The fish and the monkey
The platinum rule
• Do unto others as the other would
want to be done to.
What is culture?
Culture:
• “is the way people do things.”
Antonio Guzman, Desana tribesman and anthropologist
• “is the way people do things.”
Naomi Lewy in 8th grade
Cultures
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Ethnicity
Religion
Sexual orientation
Occupation
Class
The culture iceberg
• Above the water:
• Behavior
• Language, customs
• Artifacts:
• clothing, food
• Below the water:
• Beliefs
• Values
• Assumptions
• Adapted from Benson-Quaziena and
Distelhorst, 2006
We need to learn about the cultures of the
populations we serve but
“Data about the beliefs, attitudes,
preferences and behaviors of groups cannot
be used to predict the beliefs, attitudes,
preferences and behaviors of individuals.”
• Blackhall, L. et al (2001)
We need to learn about the beliefs,
attitudes , preferences and behaviors of the
individuals and families with whom we
work.
What are our tools for assessing
cultural issues?
• Knowledge of the cultures of the populations we serve.
• Reading
• www.ethnomed.org
• Cultural consultation
• Contact with the communities
• Asking patients and families.
• Eliciting an explanatory model.
• Kleinman’s questions
Two views
Illness
• Client, family,
community view
• Elicited by listening
Disease
• Medical diagnosis
• Elicited by history,
physical exam radiologic
and laboratory tests
Kleinman’s Explanatory Model
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What do you call this problem?
What do you believe is the cause of this problem?
What course do you expect it to take?
How serious is it?
What do you think this problem does inside your body?
How does it affect your body and your mind?
What do you most fear about this condition?
What do you most fear about the treatment?
PLoS Medicine | www.plosmedicine.org 1673 , October
2006 | Volume 3 | Issue 10 | e294
The LEARN Model
•Listen
•Explain
•Acknowledge
•Recommend
•Negotiate
Berlin EA, Fowkes WC ,1983
Resources
• Interpretation agencies
• Ethno Med: http://ethnomed.org
• Cultural consultation
http://ethnomed.org/