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Abstract

Patients with limited English proficiency (LEP) are more likely to experience suboptimal health care outcomes, including avoidable emergency department visits and hospital readmissions. Despite legal requirements in the United States to provide patients with LEP language access services such as certified interpreters during care encounters, gaps in these necessary care processes persist. Nurses provide the majority of direct care to patients with LEP in hospitals and oversee the implementation of necessary language access services. The objective of this qualitative study was to describe nurses’ experiences providing care to patients with LEP in hospitals to inform actionable strategies for high-quality patient care for this population. A directed content and thematic analysis of 1295 open text responses from the RN4CAST-NY/IL survey of hospital nurses was conducted, informed by the Social Ecological Model. Four themes were identified: (1) Sufficient and Expert Nurse Staffing ; (2) Community-Integrated Teams and Programs; (3) Variation in Language Access Availability and Modalities; and (4) Tailored Language Access. Nurse-endorsed strategies to improve LEP patient care, informed by the themes, include: improving the adequacy and expertise of nurse staffing to include a multilingual workforce; developing community-integrated teams and programs informed by the lived experiences of LEP patients; developing hospital standards for the type of language access services patients receive in care encounters; and developing protocols to ensure that tailored services are delivered to patients depending on their unique care needs (eg, visual or hearing impairment).

Keywords

language limited English proficiency nurse hospital care nurse work environments

Highlights

Patients experiencing communication barriers experience disproportionately worse outcomes including higher rates of emergency department revisits and hospital readmissions.

Nurses in this study identified strategies to reduce disparities in care outcomes including expanding the multilingual clinician workforce, advancing community-integrated teams within hospitals, and standardizing language services for consistent clinician access and use.

Introduction

Clear and comprehensive communication between patients and clinicians is an important determinant of high-quality health outcomes.^1-4 Patients with limited English proficiency (LEP)—defined as individuals who do not speak English as their primary language and have limited ability to read, speak, write or understand English— experience disproportionately worse care outcomes in outpatient and inpatient settings as compared to non-LEP patients due in part to language barriers that compromise equitable health care delivery.^5,6 Compared to those without LEP, patients with LEP experience higher odds of 72-h ED revisits,⁷ hospital readmissions,⁸ and are more likely to report dissatisfaction with care.^5,9-11 Institutions (eg, hospitals) that receive federal funding from the U.S. government are legally mandated to provide language access services to individuals with LEP based on Title VI of the Civil Rights Act of 1964.⁶ Section 1557 of the Affordable Care Act further defines language access laws, such that language access services (eg, in-person, telephonic, or video interpreters) must be provided free of charge, and by qualified interpreters. The law also requires that hospitals provide taglines indicating the availability of language services on all significant hospital documents, in the top 15 non-English languages in the state.¹²

Despite these legal provisions, there is wide variation in the availability, quality and use of language access services by clinicians in caring for LEP patients across hospitals,¹³ which may contribute to disparate outcomes. Further, little is known about what strategies should be prioritized within hospitals to advance more equitable care for this growing population in the U.S.¹⁴ As the clinicians who often first identify a language barrier and utilize language access services, nurses are ideally positioned to provide important insights about the care delivery process for LEP patients and how care could be improved.¹⁵ Nurses are on the frontlines of patient interaction and frequently responsible for coordinating care, advocating on behalf of patients, and providing critical patient education. Understanding the factors that may facilitate or impede the delivery of high-quality care to patients with LEP from the nurse perspective can provide foundational knowledge about how to promote more equitable outcomes for this patient population.

Prior studies have described nurses’ experiences providing care to patients with LEP,^5,7,9-11 with few focused on identifying solutions to improve care for the LEP population. Therefore, the objective of this qualitative study was to describe nurses’ experiences caring for patients with LEP with a particular focus on the identification of challenges and facilitators. We also sought to identify nurse-endorsed strategies that could be adopted by hospitals to enhance high-quality and equitable care delivery.⁵

Methods

Study Overview

This qualitative study was an analysis of open-text survey data collected from hospital-employed nurses in New York and Illinois. The approach for the analysis was informed by a prior study that aimed to understand nurses’ perspectives on what helps or hinders care of socially disadvantaged populations.¹⁶ The present study focused specifically on nurses’ care relevant to LEP patients. Study protocol was deemed exempt by the University of Pennsylvania Institutional Review Board. The COREQ guidelines were followed.

Data Source

The open text response data were derived from the RN4CAST-NY/IL survey of registered nurses licensed to work in New York and Illinois. The RN4CAST-NY/IL survey was an email-based survey conducted between December 2019 and February 2020.¹⁷ Nurses responded to questions about their demographics, the quality of their hospital work environment, the quality and safety of patient care, and well-being outcomes such as job satisfaction. In collaboration with the National Council of State Boards of Nursing, 100% of nurses licensed to work in New York and Illinois were invited to participate in an online survey via email. Our method of sampling nurses directly through licensure lists is preferred over approaching hospitals given the potential risk for non-response bias, where hospitals with suboptimal outcomes may be less inclined to participate. Prior literature^18-20 outlines the RN4CAST-NY/IL methodology in detail.

The sample for this study included 1295 nurses (see Supplemental File for sample inclusion) who responded to the open text question: “What helps (or hinders) your ability to provide quality care to vulnerable populations? (eg, low SES, housing insecurity/homeless, racial/ethnic minorities, immigrant, limited English proficiency)?”

Theoretical Model

The Social Ecological Model²¹ was the conceptual framework guiding the qualitative analysis. The SEM conceptualizes phenomena as influenced by overlapping inter-related levels: systems, community, institutional and individual. The SEM was applied to the prior qualitative study²² and was used to inform the study codebook and inductive and deductive coding for the directed content and thematic analyses. The analytic focus for the present study was on nurses’ descriptions of their experiences caring for patients with LEP specifically to inform care strategies.

Analysis

The open-text data were exported to an Excel file, de-identified, and uploaded to qualitative software NVivo. The codebook for the analysis was developed in the prior qualitative study about what nurses say helps or hinders the care of socially disadvantaged patients. We developed codes deductively, informed by literature on the care of populations such as the unhoused or those with LEP; as well as inductively through open coding of the data. We identified codes for the codebook across each SEM level (eg, “code: Language barriers” (Individual level); “code: Equipment and technology” (Institutional level)) with example quotes. Deviant quotes were those that were contradictory in promoting high-quality care to patients with LEP, the core objective of the paper, (eg,: “Too many illegal immigrants and open borders.,” RN #988). We coded all nurse responses to the open-text question and were specifically interested in analyzing responses relevant to communication with LEP patients, addressing the social determinants of health, and nurses’ lived experiences in multiculturalism and bilingualism. Two researchers independently read all responses initially for a general overview of the content, then coded a 20% subset of the data for coding agreement. The data were coded using directed content analysis with a specific emphasis on the content and tone of the nurses’ open text responses, as well as a focus on the facilitators and challenges to care for LEP patients.²³ After the agreement was achieved on coding, (IRR ≥ 0.60), one researcher then coded the entire dataset using the codebook.²⁴

The research team met regularly over 3 months to discuss the initial patterns in the data, developing high-level categories such as “Equipment” and “Health literacy.” A thematic analysis²⁵ was conducted of emerging categories in the data, identifying illustrative quotes and deviant quotes. The researchers returned to the data and iteratively applied memos to the data to contextualize categories, leading to the eventual identification of study themes. Data saturation was achieved when no new themes were identified at 866 responses. However, we continued coding the remaining 429 responses (up to 1295) to ensure thoroughness and confirm that saturation had been reached. This allowed us to verify the consistency of themes across the dataset. Strategies were identified across each study theme and SEM level by synthesizing the facilitators and challenges of providing quality care to LEP patients with quotes in which nurses described what interventions helped or hindered care to this population.

Methods to ensure rigor and trustworthiness^26,27 were upheld including reflexivity and documentation of positionality statements; inclusion of a diverse study team of non-native English speakers and bilingual clinicians; clinicians with experience caring for individuals with LEP; recording an audit trail; and discussion of findings within the larger research group.

Results

Four themes were identified from the thematic analysis to inform care delivery for patients with LEP: (1) Sufficient and Expert Nurse Staffing; (2) Community-Integrated Teams and Programs; (3) Variation in Language Access Availability and Modalities; and (4) Tailored Language Access. The demographics of the nurse sample are provided in Table 1. Themes are described across SEM level with exemplar quotes outlined in Table 2 and nurse-endorsed strategies provided in Table 3. Frequency of study themes are outlined in Figure 1 and our findings are ordered by how commonly they were referenced by nurses.

Table 1.

Nurse Demographics.

Characteristics	Nurses N = 1295
Characteristics	N/mean	%/SD
Age	47.7	17
Years as an RN	19	14
Sex, female	1178	92
Race
American Indian or Alaskan Native	NR	NR
Asian	147	11
Black or African American	188	15
Native Hawaiian or Other Pacific Islander	NR	NR
White	832	65
Other race	115	9
Hispanic ethnicity	103	8
Staff nurse	907	70
At least a BSN	1156	89

Note. Not all open text respondents completed demographic information in the RN4CAST-NY/IL survey; BSN = Bachelor of Science in Nursing; NR = not reported due to small cell size required by the CMS Cell Suppression Policy; RN = registered nurse. The authorship team acknowledges that limitations of not reporting all race demographics exacerbate existing inequities in the reporting of indigenous populations. a “Other race” category included write-in responses from nurses (eg, “Multiple race”; “Filipino American”). Column totals may not equal 100% due to missingness and/or rounding.

Table 2.

Exemplar Quotes From Thematic Analysis.

SEM level	Theme	Quote
System	Sufficient and expert nurse staffing	Interpreter services are available. Many staff are bilingual. Hospital has a micro food pantry available 24/7. Staff turnover impacts staffing. [RN #54]
		I feel hindered because I am not bilingual in Spanish. It is tedious using the interpreter phone. [RN #95]
		Poor staffing ratios make it difficult to find time to track down appropriate translators. [RN #501]
		I do not speak Spanish - this limits interpersonal interaction with my Spanish speaking patients [RN #582]
Community	Community-integrated teams and programs	We had a community social worker that spoke Spanish and was wonderful. [RN #110]
		I am lucky to work in the community in which I live so I already have a rapport with many of my patients. I think this helps with my patient’s perspective of the care I am rendering. [RN #107]
		Our staff is used to helping patients that have extra needs, as the community is very diverse. Although, we can all always be learning more. We have translators, language lines. I think sometimes it is a matter of resources to help people outside the hospital that seem to lack. [RN #812]
Institutional	Variation in language access availability and modalities	The organization does a good job providing language lines and video translation. It would be awesome to have in person translator at least for Spanish because we have high Spanish speaking population. These patients usually stay a bit longer for case management to resolve some of their issues or setting up resources. [RN #134]
		Sometimes a language barrier and the translating service we use makes it difficult to communicate; there is some disparity with how people are treated based on condition and mental health. [RN #71]
		Having confused patients who do not speak English and cannot use Cyracom translator phones
Individual	Tailored language access	Having more in-person interpreters available 24/7 would allow us to better care for vulnerable populations, who in addition to speaking a different language, may have poor vision or difficulty hearing, for which a telephone or video interpreter does not work. [RN #69]
		Poor health literacy, mistrust in the healthcare community, housing insecurity [RN #201]
		By understanding their background and provide information at a level they can understand [RN #216]

Note. Each quote represents a unique nurse response.

Table 3.

Nurse-Endorsed Strategies by Study Theme.

SEM level	Theme	Strategies
System	Sufficient and expert nurse staffing	Adequately staff nurses in hospitals to care for patients with LEP
		Integrate patient language needs into nurse staffing assignments
		Actively recruit multilingual nurses in health care jobs
		Provide cultural competency trainings for clinicians in language equity topics
		Provide incentives and compensation for nurses applying their foreign language skills at work
Community	Community-integrated teams and programs	Actively recruit multilingual staff members whose lived experiences in the community reflect those of LEP patients
		Invest in multi-disciplinary teams to facilitate care connections from hospital to outpatient care (eg, social work)
		Advance transitional care and other community-embedded programs to connect patients with outpatient services post-hospital discharge
Institutional	Variation in language access availability and modalities	Ensure that hospitals are upholding legal requirements to offer language access services
		Adequately resource hospitals with sufficient and high-quality language access equipment (eg, interpreters)
		Ensure consistent access via standardization for the types of language modalities provided in hospitals.
Individual	Tailored language access	Provide individualized language access services to patients based on their clinical and social presentation
Individual	Tailored language access	Document patient preferences for language access modalities for care continuity across health care encounters

Figure 1.

Frequency of study themes in analysis.

SEM Level: System

Theme 1: Sufficient and Expert Nurse Staffing

To improve care for patients with LEP, nurses described the need for sufficient nurse staffing in terms of both numbers and tailored expertise. Inadequate staffing hindered nurses’ ability to spend adequate time delivering high-quality care to patients with LEP.

Several nurses stated:

Not having the staff to adequately care for patients which prevents me from being able to provide resources to those in need. [RN #21]

Helps: translators, patient education in many languages, less patient ratio = more time spent with each patient [RN #54]

In addition to having a sufficient number of nurses, ensuring that the nursing staff was comprised of multilingual individuals who understood the language and cultural experiences of LEP patients was essential. Several nurses described how a lack of employer investment in a tailored workforce impacted LEP patient care:

I do not have a comprehensive understanding of the unique perspectives and experiences of this demographic. Therefore, I struggle with connecting to these patients and struggle with providing effective education. Also, I feel like I do not have a strong understanding of the various resources available to help vulnerable populations, such as food assistance, financial assistance, etc. [RN #90]

Diversity of staff: Ethnicity and race of staff at all levels does not represent the population we serve [RN #445]

Biggest hinderance is that I only speak English [RN #536]

Working with a healthcare staff comprised of bilingual nurses and other healthcare professionals reduced barriers to quality care, as several nurses described:

I also speak Portuguese, so it helps with patient care when someone has limited English proficiency. [RN #72]

We have translator phones, MD, PA & RNs that are bilingual. We also have a very diverse workforce that helps us to understand different cultures [Nurse #257]

Insufficient staff who are bilingual Spanish. Interpretive services just cannot provide the care needed in psychiatry that a clinician who is at least proficient in Spanish can provide [RN #8]

SEM Level: Community

Theme 2: Community-Integrated Teams and Programs

Nurses identified the need for interdisciplinary teams that were collaborative with the communities where LEP patients reside. One nurse described a potential care model:

A strong interdisciplinary team with nurses at the forefront helps to manage the vulnerable population. The use of interpreter aids help to assist with LEP patients. Dedicated social workers and care managers assist vulnerable patients to navigate the healthcare system [RN #96]

One nurse described how her own lived experience in the community helped care for patients with LEP: “What helps is that I grew up in my community where I work and speak Spanish.” [RN #79]

Several nurses described the need for hospital-community programs that provided aid for social services and legal support for patients with LEP:

. . .the pandemic has hindered greatly my patients struggling in a changing community, undocumented, unable to pay rent and buy food. We need more programs like Bridge Back to Life and [National Association on Drug Abuse Problems]; 311 is also very helpful in caring for my patients. [RN #80]

We have a very diverse community and because of this we do encounter families with limited English proficiency. We luckily have resources to support them and nursing when trying to provide patient education and care updates. [RN #38]

SEM Level: Institutional

Theme 3: Variation in Language Access Availability and Modalities

Registered nurses discussed a lack of available language access services in their hospital due to missing or broken equipment or the inability to use available equipment in a timely manner including telephonic and video interpreters. As one nurse described, “Interpreting services, sometimes have technical issues with portable interpreting monitor.” [RN #201]

Another nurse stated, “Interpreting devices are slow and there are only 2 video devices in our unit” [RN #123]

Readily available equipment was a facilitator to high-quality care for patients with LEP in hospitals that supported such services. One nurse stated, “I feel my hospital is pretty good at this. We have a language line that’s accessible at all hours of the day to translate almost any language.” [RN #70]

Nurses discussed the following modalities for interpretation and translation: video interpretation (eg, iPad); telephonic (eg, Cyracom); and in-person interpreters. The variation in modalities was described by nurses:

The language assistance iPad helps [RN #67]

Video interpreter service helps [RN #15]

We need translator phones [RN#118]

There was variation in the type, quality, and quantity of modalities for language access services as described by nurses. Nurses described the need for specific modalities that they viewed as more favorable than others:

Provide English translators in person rather than video or phone. [RN # 610]

We used to have in-person interpreters which was better than the phone system we use now [RN #122]

SEM Level: Individual

Theme 4: Tailored Language Access

Not all modalities were treated equally in terms of the quality of interpretation, as described by nurses. As one nurse stated, there were “. . .language barriers even with translation devices” [RN #173]. For example, nurses cited challenges with modalities based on patient presentation. If patients presented symptoms or care needs impacting their communication (eg, non-invasive ventilation masks that can be noisy) the video or telephonic interpreters did not always facilitate this care.

Limited interpreters and non-in-person interpreters for patients on high oxygen needs like [Bilevel Positive Airway Pressure], a video or phone interpreter doesn’t work [RN#9]

Nurses also described the need to address health literacy in addition to patient language needs as an overlooked aspect of communication for the LEP population. One nurse stated, “Many patients in my hospital do not speak English. [There is] poor health literacy of the population being treated at my facility” [RN #101].

Discussion

This qualitative study identified 4 themes to inform nurse-endorsed strategies in delivering high-quality care to patients with LEP across system, community, institutional, and individual domains of the Social-Ecological Model. Our findings underscore key priorities for hospital employers to improve care for the over 25 million individuals in the U.S. with LEP.⁶ The theme “Sufficient and Expert Nurse Staffing” was the most commonly cited, however, combined, the 2 themes of “Variation in Language Access Availability and Modalities” and “Tailored Language Access” were referenced the most by nurses.

Solutions to improve care for individuals with LEP, informed by nurses in our study, include improving the adequacy and diversity of nurse staffing to ensure that the nursing workforce in hospitals is comprised of multilingual nurses. Prior literature indicates that having a sufficient number of nurses at the bedside is critical for high-quality care to socially disadvantaged patients,^28,29 including those with LEP.²² Adequate staffing is also a key feature of optimal nurse work environments, and prior evidence indicates that when nurses work in a higher-quality nurse work environment, LEP patients experience lower odds of a repeat ED visit or hospitalization.^5,7

However, sufficient staffing is not the only aspect of nurse staffing that matters for optimal LEP patient care.^5,27An increase in staffing does not necessarily ensure the presence of appropriately qualified personnel—such as certified bilingual staff—or the availability of adequate language services to effectively meet the needs of individuals with limited English proficiency; thus, various nurse staffing factors should be comprehensively considered to best improve care delivery for patients with LEP. Multilingual nurses in our study described the benefits of their cultural and foreign language skillset in providing care to patients with LEP. Such perspectives from nurses are supported by over 20 years of evidence demonstrating that patients with LEP experience better outcomes when they receive language concordant care from clinicians.^1,30,31 Nurses who were not multilingual reported a strong interest in receiving training in developing proficiency in languages other than English.

Hospitals can invest in a multilingual workforce by offering either on-site language programs or reimbursement for language learning. Hospitals should also sponsor interpreter trainings for clinicians who speak languages other than English given that informal interpretation is not legally permitted in health care settings.³² Compensation is needed for clinicians who provide medical interpretation given their highly valuable skillset.³³ Finally, regardless of clinician language proficiency, hospitals should provide cultural competency training surrounding the care of patients with LEP. Such trainings can address provider-patient language concordance, legal requirements surrounding language access services, and the demographics and lived experiences of patients in the U.S. who speak languages other than English (eg, percentage of LEP patients that are immigrants; majority non-English languages spoken).

Investing in hospital teams and programs that were embedded within the communities where LEP patients reside was an important strategy that nurses identified to improve LEP care. To optimally address the clinical and social care needs (eg, housing, transport support) of LEP patients, nurses suggested that community health workers and social workers with knowledge of local communities and neighborhoods be recruited and incorporated within the hospital care team. Prior literature^34,35 supports the integration of community case workers within hospitals who can connect patients with LEP to primary care visits, specialty visits, and assist with financial and transportation resources. Nurses also described the need to expand or re-introduce programs that were sunset in their hospital that provided optimal transitional care opportunities for LEP patients.

Standardization of the type of language access services provided in hospitals is needed. At present, there are no specific guidelines surrounding whether hospitals are required to have in-person or telephonic interpreters. With emerging technologies including artificial intelligence and video interpretation through tablets, consistency is needed for LEP patient care processes. Language access services equipment should be regularly serviced to ensure that clinicians do not encounter operational delays in obtaining and using interpreter services. Evidence from this study and others demonstrates that operational failures^36,37 such as broken equipment in health care settings are associated with poor patient quality and safety outcomes. Hospitals must develop dedicated, multi-disciplinary committees to regularly ensure that organizations are optimizing language access services. One approach to standardization is to include structured guidance around LEP patient care requirements within Magnet designation requirements. Magnet-designated hospitals uphold existing standards that promote high-quality nursing care (eg, nurse autonomy and leadership; involvement in research). Such standards can be informed by the Civil Rights Act of 1964⁶ and the Joint Commission’s guidance around LEP patient care and rights.³⁸

Finally, all patients with LEP should be comprehensively assessed in terms of clinical presentation and health literacy.³⁹ Despite the availability of language access equipment, patients may experience challenges with education in the clinical setting due to low health literacy. For example, clinicians must evaluate patient health literacy through teach-back-strategies, the use of plain language documents, and connecting patients with case managers and/or patient advocates.⁴⁰ Additionally, patients who may have visual or hearing impairment need specialized care communication strategies in which interpretation delivered via tablets with closed captioning may be beneficial. Establishing clinical protocols and guidelines that outline nuanced patient presentations that require tailored language access services is essential.

Limitations

Our study analyzed qualitative data from nurses employed in New York and Illinois hospitals discussing experiences with LEP patient care, limiting generalizability across all hospitals and populations. However, as a qualitative investigation in which the methodological goal was to provide transferability rather than generalizability, we provide a comprehensive overview of study findings about LEP care that can be contextualized to other health care settings. Our analysis also includes thousands of open-text responses from nurses across a diverse set of hospital units despite being limited to 2 states. Not all responses from nurses specifically denoted caring for patients with LEP; however the data broadly address important care considerations to socially vulnerable populations, which includes patients with LEP. Our analysis focused on topics relevant to LEP care including patient communication, language access equipment, addressing the social determinants of health, and nurses’ lived experiences as multicultural, bilingual individuals.

Conclusion

Across 4 study themes, hospital nurses described their experiences delivering care to patients with LEP, informing strategies to improve care quality for this population. Study themes identified the need for adequate and expert staffing, community-integrated teams, and specific recommendations for the language and equipment needed to improve language access for patients with LEP.

Supplemental Material

sj-docx-1-inq-10.1177_00469580251370934 – Supplemental material for Improving Hospital Care for Patients Experiencing Communication Barriers Through Nurse-Endorsed Strategies

Supplemental material, sj-docx-1-inq-10.1177_00469580251370934 for Improving Hospital Care for Patients Experiencing Communication Barriers Through Nurse-Endorsed Strategies by Kathryn Jane Muir, Kathy S. Sliwinski, Lee Ang, Kelvin Amenyedor, Ann Kutney-Lee and Jacqueline Margo Brooks Carthon in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

The authors wish to thank Daniela Golinelli for her statistical support.

ORCID iDs

Kathryn Jane Muir

Jacqueline Margo Brooks Carthon

Ethical Considerations

The study protocol was deemed exempt by the University of Pennsylvania Institutional Review Board.

Consent to Participate

Consent was assumed upon participant initiation of our study survey, and was approved by our IRB.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is funded by the National Institutes of Health, National Institute for Nursing Research, R01NR020471(MBC and AKL) and K01NR021419 (KJM). Support was also provided by the Agency for Healthcare Research and Quality AHRQ R01HS028978 (KB Lasater) T32HS000078 (Sliwinski) and the National Council of State Boards of Nursing (KB Lasater). The content is solely the responsibility of the authors and does not necessarily represent the official views or policies of the National Institutes of Health, Agency for Healthcare Research and Quality, the National Council of State Boards of Nursing, the U.S. Government, the U.S. Department of Veterans Affairs, or the U.S. Department of Health and Human Services.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data are not available for data sharing purposes.

Supplemental Material

Supplemental material for this article is available online.

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