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Abstract

Background: In September 2020, Governor Gavin Newsom of California signed Assembly Bill 890 (AB 890) into law, which changed Title 16 of the Nurse Practice Act, granting California nurse practitioners (NPs) a stepwise approach to full practice authority. Written within the law, NPs are required to verbally identify themselves specifically to all Spanish-speaking patients, as enfermera(o) especializada (o). Local Problem: AB 890 requires NPs to identify themselves using inappropriate Spanish terminology. There are concerns regarding the translational accuracy of nurse practitioners under AB 890. To avoid confusion, it is essential to ensure the translation of the NP role is precise and unambiguous to ensure health equity. Context: This law has a significant impact on approximately 37,000 NPs in the state of California who provide essential healthcare services to the Spanish-speaking community. Critically, the Hispanic/Latino community accounts for almost 40% of California state's population, and Intervention: This literature review will delve into the current literature for the accurate Spanish terminology of the “Advanced Practice Nurse,” “Advanced Practice Registered Nurse,” and Nurse Practitioner.” Outcome Measures: To accurately translate “Advanced Practice Nurse,” “Advanced Practice Registered Nurse,” and “Nurse Practitioner.”

Keywords

California AB 890 enfermera especializada enfermero especializado unified lexicon

Problem Statement

The World Health Organization (WHO) asserts that health equity is a “fundamental human right” (WHO, 2024) and “the absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically” (WHO, 2024). The United States is committed to achieving health equity in accordance with the WHO's principles. The overarching goal of the US Health People 2030 is to “eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all” (Healthy People, 2030, 2024).

An important step to achieving health equity and eliminating healthcare disparities is expanding quality healthcare access (Healthy People, 2030, 2024; Thornton et al., 2016). On January 1, 2023, California enacted Assembly Bill 890 (AB890). The bill was signed into law in September 2020 by Governor Gavin Newsom. California's AB 890 law offers California's state nurse practitioners (NPs) a stepwise approach to achieving full practice authority (FPA). California NPs joined 27 other states in independent practice.

In the United States, the designation of an advanced practice nurse (APN) and advanced practice registered nurse (APRN) applies to a registered nurse who holds an advanced degree, typically a master's degree or higher. The American Nurses Association (2023) identifies four specialty roles within the APN/APRN umbrella: nurse practitioners (NPs), clinical nurse specialists (CNS), certified registered nurse anesthetists (CRNA), and certified nurse midwives (CNM). While the laws and scope of practice vary from state to state, NPs are educated to diagnose, treat, and prescribe medications to patients, with and without direct physician involvement. They can work independently, subject to state-specific NP regulations.

California AB 890 changes to Title 16; Section 1487b of the Nurse Practice Act introduced two concerns for Spanish-speaking nurse practitioners and their patients. California now requires NPs to communicate verbally with their Spanish-speaking patients by explicitly identifying themselves as an enfermera especializada or enfermero especializado in their interactions with patients (California Code of Regulations Title 16, 2023).

First, the direct literal Spanish translation of nurse practitioner is enfermera practicante (DeepL Translate, 2023; Google Translate, 2023a, 2023b), and the literal translation of enfermera especializada to English is “specialized nurse” (Google Translate, 2023a, 2023b). The term enfermera (o) especializada (o) inaccurately portrays NPs as “specialized nurses” rather than advanced nurse practitioners. Second, requiring NPs to explicitly state that they are not physicians or surgeons has the potential to diminish patients’ trust and deter them from seeing an NP, which may, in turn, delay access to care and timely treatment.

To achieve health equity and close the gap in health care disparities for Hispanic/Latinx patients, a unified lexicon among Hispanic/Latinx nurses for the most accurate translation of the Nurse Practitioner is sought. This literature review's primary goal is to demonstrate the need for the most precise and accurate translation of the “advanced practice nurse (APN),” “advanced practice registered nurse (APRN),” and “nurse practitioner (NP).” Clear and effective communication is essential in the healthcare system, and a unified language is crucial for promoting clarity of roles and responsibilities. Its absence can undermine diversity, equity, and inclusion initiatives and harm patient health outcomes and overall quality of life (Stamps et al., 2022).

Background

Over 355,000 licensed NPs in the United States provide more than one billion patient visits annually (American Association of Nurse Practitioners, 2023). The changes to the California Nurse Practice Act imposed by AB 890 affect more than 37,000 NPs in California (BRN, 2023), of which 8.4% are of Hispanic/Latinx ethnicity (Spetz et al., 2017). In 2019, the California Health Care Foundation published a fact sheet on the importance and implications of expanding FPA for NPs in California. At the time of publication, NPs provided 59% of primary care visits compared with 17% of their physician colleagues. NPs are more likely than physicians to provide primary care to underserved populations and more likely to see new Medi-Cal and uninsured patients. Access to primary care is greater when NPs have FPA. States that allow FPA report fewer hospital admissions and emergency department visits, positively impacting state budgets (California Health Care Foundation, 2019).

According to the most recent estimates from the US Census Bureau (2022), California's population is estimated at 39 million, with the Hispanic/Latinx population accounting for 15.7 million (40.3%) (U.S. Census, 2022). However, the California Health Care Foundation (2022) found that 20% of Hispanic/Latinx Californians faced challenges in accessing healthcare, lived in areas with provider shortages, and tended to delay physical healthcare appointments.

Patients often develop strong and trusting relationships with NPs, relying on their advanced education and clinical training, holistic approaches to wellness and health maintenance, and guidance for their healthcare needs. Referring to NPs as “specialized nurses” might inadvertently sow doubt about their competence and capabilities, which are critical in delivering quality healthcare. NPs undergo rigorous training to provide a wide range of healthcare services, and their contributions are vital to addressing the growing demand for accessible and affordable medical care. Additionally, requiring NPs to explicitly state that they are not physicians risks diminishing the NPs’ knowledge and expertise in the eyes of their patients. This underscores the importance of transparent and truthful communication when stating the role of NPs, particularly within the Hispanic/Latinx community.

Specific Aim

To ensure effective communication and promote health equity for California's Hispanic/Latinx population, it is crucial to accurately identify NPs as providers to their Spanish-speaking patients. Unfortunately, the current translation of NPs in the Nurse Practice Act is inaccurately translated to Spanish as enfermera(o) especializada (o) (i.e., specialized nurse). This has raised concerns in the Hispanic/Latinx nursing community because it may lead to patient misunderstanding, thus hindering patient confidence in the NP and subsequent delivery of quality care. To address this issue and promote effective communication and health equity, it is necessary to use the correct terminology to identify NPs and foster a shared language between healthcare professionals and patients.

Available Knowledge

In California, the law mandated that NPs introduce themselves in Spanish as an enfermera (o) especializada (o). However, this translation is not entirely accurate for NPs.

PICOT Question

The following PICOT question will guide the search for the best scientific evidence (Melynk & Fineout-Overholt, 2019): For NPs in California who speak Spanish to their patients (P), how does the terminology for the NP role, enfermera practicante avanzada, enfermera practicante or enfermera de practica avanzada (I) compared with current practice/terminology required by AB 890 enfermera (o) especializada (o) (C) affect trust and confidence of their patients (O)?

Search Methodology

The Preferred Reporting Items for Systematic Review (PRISMA) 2020 guidelines were used for systematic review articles and meta-analysis. The Joanna Briggs Institute (JBI) Critical Appraisal tools were used to assess the studies’ methodological quality (Aromataris & Munn, 2020). Articles for review published in Spanish and English over the last fifteen years included original quantitative experimental, quasi-experimental, or observational studies. Papers were excluded if they did not comply with PRISMA, CONSORT, or STROBE guidelines. Four databases were queried: Google Scholar, PubMed, MEDLINE, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The search terms used across the four databases were “enfermera especializada” or “enfermera practicante” or “enfermera de practica avanzada” or “enfermera especialista” or “enfermera registrada de practica avanzada” or “enfermera practicante general” or “APN” or “APRN”. The phrase “nurse practitioner” in Spanish was searched on the world wide web search engines (Bing, Google, Yahoo! Search, YouTube) for cultural translation and a search for Spanish translations of “nurse practitioner” in Spanish university degree programs.

The impetus behind AB890 was to grant NPs FPA. Five key themes were identified from the literature review: (a) What advantages does FPA bestow upon NPs? (b) What is the origin of the term “enfermera (o) especializada (o)?” (c) Advanced practice nurses, specifically NPs, do not exist in Latin America. (d) The Hispanic/Latinx values and attitudes toward healthcare providers in the United States. (e) The impact of the wrong interpretation of the nurse practitioner in Spanish.

Integrated Review of the Literature

Nurse Practitioner FPA

This research revealed two important systematic and literature reviews that provide valuable insights into the impact of FPA on the healthcare community. Yang et al. (2021) conducted a comprehensive literature review to evaluate variables related to the impact of NP practice on structures, processes, and outcomes within healthcare. They used four databases: Medline; CINAHL; PubMed; and PsychINFO. Initially, 3041 articles were identified through the search. After eliminating duplicates and articles not located in the United States within the required years and assessing eligibility, 33 relevant articles remained. The literature review findings indicate that FPA positively impacts healthcare delivery in the United States. NPs increased presence led to enhanced care processes, improved access to healthcare, and higher utilization rates. Importantly, patient care outcomes and sustainability were not adversely affected by the expansion of NP practice under FPA regulations. These results highlight the potential benefits of granting NPs FPA in healthcare systems, contributing to more effective and accessible patient care without compromising health outcomes.

In a systematic review of the literature by Ying Xue et al. (2016), 529 published articles in PubMed, CINAHL, PsycINFO, and Cochrane Library were screened. After applying inclusion and exclusion criteria, 15 studies were included in the review. Xue et al. (2016) identified three key findings. First, four studies demonstrated that states granting NPs full scope-of-practice authority experienced an increased number and growth of NPs in the workforce. Second, five studies found that states with expanded practice authority showed greater growth and advancement of NP primary care provisions, particularly in rural and underserved communities. Third, one study indicated a significant impact on access to preventive care. In contrast, another study revealed the economic impact, observing higher clinic costs in states with more restrictive NP practices compared with those with full or reduced scope of practice.

Origin of Enfermera(o) Especializada(o)

The term “enfermera especializada,” used under California law to refer to NPs in Spanish, seems to have originated from “nurse specialist” (NS) used in the European Union and Spain's National Health System through Royal Decree 450/1987. In 1987, this decree recognized advanced nursing education and nurses specializing in various specialties. In an editorial review in 2009, Roberto Malo discussed the regulated specialized nurse (NS) role in the European context. He highlighted the need for Spain to develop a new specialized advanced practice nurse subspecialty. Malo differentiated between NPs and NS: the NP is enfermera practiticante/ enferemera de practica avanzada, while NS is enferemera especialista. Malo (2009) explained that an NS is a specialized nurse with advanced preparation in a specific area of nursing beyond the general nurse level. On the other hand, an advanced practice nurse provider (NP) has a broader scope of competencies than an NS.

Malo's (2009) editorial highlighted two significant points concerning California's laws regarding nurse providers. First, it highlighted that the Spanish language does not adequately explain nurse providers’ responsibilities in the state. Second, it emphasized that there is a distinction between the terms NS and clinical nurse specialist, with the latter falling under the domain of APRNs while the former does not. Garcia et al. (2002), “Enfermeria de práctica avanzada: historia y definicion” outline the history and definition of the advanced practice nurse (la práctica avanzada de enfermeras). The authors state that “especialista” refers to a nurse with a post-graduate degree in a specialized area, “habiendo completado un curso de postgrado en un area de especialidad” (Garcia et al., 2002, p. 287). Garcia and associates (2002, p. 287) further explain that in the 1970s in the United States, the term “enfermeria de práctica avanzada” referred to four specialties “la enfermera anestesista (nurse anesthetist), la enfermera matrona (nurse midwife), enfermera clinica (clinical nurse) y la enferemera practicante (nurse practitioner).” The authors emphasized that the term “nurse provider” used in this article does not correspond to the term “practitioner” in Spanish. “Practicante” in Spanish is “practicing” and not seen as a practitioner or provider of healthcare (Garcia et al., 2002, p. 289).

Advanced Practice Nurses, Specifically Nurse Practitioners, Do Not Exist in Latin America

Ferrer et al. (2023) reviewed 405 articles published from 2010 to 2020. Against the PICO question of (P) “Enfermera de Práctica Avanzada (I) implementaction de la EPA en Atencion Primaria de Salud,(C) no existe comparative y (O) experiencias [translation: (P) advanced practice nurses (I) implementation of the advance practice nurse in primary health care (C) nonexistent comparative (O) experiences]. Ferrer et al. (2023) state, “con enfasis en Latinoamerica, donde aun nose definen aspectos de regulacion, formacion ye ejercicio de la EPA” [translation: with emphasis on Latina America, where aspects of regulation, training, and practice of advanced practice nursing have not yet been defined] (Ferrer et al., 2023).

Multiple articles advocate for an advanced practice nurse in Latin America and Spain (Ferrer et al., 2023; MacKay & Hurtado, 2019; Schneider & Esparza, 2022).

The Attitudes of Hispanics/Latinx Toward Healthcare Providers

A mixed-method study conducted by Greene and Ramos in 2021, titled “A mixed methods examination of healthcare provider behaviors that build patients’ trust,” highlights several key elements crucial for patients to establish trust with healthcare providers. These elements include effective communication, quality care, and competence. The study's qualitative aspect involved interviews with 40 participants, with a higher representation of individuals from Black backgrounds, females, and those of lower incomes. The interviews were meticulously analyzed using descriptive thematic analysis, and all recordings were transcribed verbatim.

In addition, the study employed a quantitative method involving a secondary analysis of the March 2019 Health Reform Monitoring Survey (HRMS) data. The HRMS dataset consisted of 6,392 participants from various backgrounds, including Black (n = 544, 8.5%), Latinx (n = 812, 12.7%), and White (n = 4609, 72%) individuals. Eight questions were used to measure communication, caring, and competence.

Greene and Ramos (2021) found that building trust requires caring actions, such as displaying an interest in people, valuing the patient's experiences, and being committed to resolving their health concerns. The Greene and Ramos’s (2021) participants typically identified caring behavior through the amount of time spent during their visit. Competence was judged by the providers’ ability to offer information and context regarding the patient's health. Additionally, competence was a critical aspect of building trust. Participants judged the competence of healthcare providers based on their ability to provide relevant information and the context regarding a patient's health.

Their study highlighted the importance of caring actions and competence in establishing a trusting relationship between healthcare providers and their patients. By understanding these factors, healthcare professionals, including NPs, can foster better communication and trust-building with diverse patient populations, ultimately leading to improved healthcare outcomes. The key takeaway from Greene and Ramos’s (2021) study is that effective communication in healthcare involves attentive listening, providing detailed explanations and comprehensive information, and speaking clearly to ensure understanding. Participants stressed the importance of healthcare providers being “upfront and honest with them” (Greene & Ramos, 2021, p. 1225).

Dalia Magana's (2020) qualitative study, “Local voices on healthcare communication issues and insights on Latino cultural constructs,” focused on the experiences of Spanish-speaking individuals in the healthcare system. This study involved interviews with 25 participants, comprising 21 women and four men, with an average age of 55. Magana's (2020) study yielded several significant findings, including challenges with time restrictions, unfriendly encounters, difficulties with interpreters, miscommunication, and opposition to the healthcare system. Participants provided recommendations to improve healthcare providers’ communication, such as actively listening, offering detailed explanations, paying close attention to what patients say, and allowing them to express themselves.

Magana's (2020) study also highlighted an important issue of mistrust within the healthcare system among Latino participants. For these individuals, specific cultural constructs such as confianza (trust), familismo (prioritizing family), personalismo (valuing interpersonal connections), respeto (respect), and simpatia (kindness) were identified as crucial elements. Trust emerged as a significant construct, and how NPs are represented plays a key role in shaping patients’ confidence in their healthcare providers.

Impact of the Wrong Interpretation of the Nurse Practitioner in Spanish

One in five people in the United States speak a language other than English at home (Diamond et al., 2019). Research in linguistic anthropology and public health has demonstrated a correlation between health outcomes and language (Showstack et al., 2019); it is no wonder that language has emerged as a social determinant of health. A systematic review by Lisa Diamond et al. (2019) entitled “A systematic review of the impact of patient-physician non-English language concordance in quality of care and outcomes” reviewed 33 articles. The authors found that language concordance in limited English proficiency decreases health disparities and increases patient satisfaction, understanding of care, and adherence to medical regimens. This study emphasized the importance of communicating with patients in a language that they can understand, which has improved outcomes.

Luis Escobedo and colleagues’ (2022) study, “Barriers in healthcare for Latinx patients with limited English proficiency- a narrative review,” reviewed 91 articles. The authors discussed the causes and consequences of mistrust leading to perceived discrimination and emotional distress, finding that “language discordance was the best predictor of confusion, frustration, and perception of poor care” (Escobedo et al., 2022, p. 1265). The authors called for cultural fluency training, standardization of education, and fluency evaluation to ensure that patients with limited English proficiency receive the same quality of care as English-proficient patients. A patient's perception of not seeing a provider who can diagnose, treat, and prescribe necessary medical treatments leads to mistrust, frustration, and getting care that is unequal. Escobedo et al. (2022) state that these experiences influence health outcomes. The authors point out several studies with Latinx patients with chronic disease who reported dissatisfaction, which led to an increased risk of hospitalization, delay in care, and more likely to return to the emergency department (Escobedo et al., 2022).

It bears noting that if a Hispanic/Latinx patient believes that they will not be treated or evaluated by a “qualified provider,” they may opt to wait for a physician appointment. According to AMN/Merrit Hawkins’ 2022 survey on physician appointment wait time, across 15 metro markets, the average wait time to see a physician is 26 days, and some areas experience as high as 44 days. In addition to precipitating visits to emergency departments, the postponement of medical attention can give rise to an augmented disability, morbidity, mortality, and superfluous healthcare expenses, as well as loss of life.

In 2019, the United Health Group research revealed that 18 million emergency visits, which could have been treated in low-cost settings such as outpatient provider visits, contributed to $32 billion in wasteful spending (United Health Group, 2019). Furthermore, according to the California Health Care Foundation (CHCF) 2021, in 2019, 13% of emergency room visits had Spanish as their preferred language of communication. One unnecessary emergency visit has a cost avoidance of $1800; by modest calculations, avoiding 10,000 visits by providing care through NPs in an office setting can save the state $18 million annually.

Moreover, in California, approximately 3.2 million adults are diagnosed with diabetes. This signifies a substantial annual healthcare cost burden of $39.47 billion annually. Individuals diagnosed with diabetes incur an average medical expenditure of $16,750 (ADA, 2021). Notably, the state of California's “Let's Get Healthy California” task force determined that diabetes prevalence in Hispanics is 12.1 per 100 residents (Let's Get Healthy California, 2021). Failing to address uncontrolled diabetes promptly can lead to vascular complications such as stroke, cardiovascular disease, chronic kidney disease, nerve damage (feet, vision, oral, and hearing), and mental health issues (CDC, 2022). Averting preventable treatment delays for 10,000 patients in California could yield an annual saving of $167,500,000 for the state.

Conclusion

The California nursing community has expressed concerns about California's law AB 890 and its translation of the term “nurse practitioner” into Spanish. It is crucial to establish the correct translation of this term to ensure effective communication within the Hispanic/Latinx community and promote health equity. The translation of the “advanced practice nurse” and “advanced practice registered nurse” is “enfermera (o) de práctica avanzada.” Demonstrating the literal and social translation of the word “nurse practitioner,” the most accurate translation is “enfermera (o) practicante avanzada.” These accurate translations are crucial for compliance with legislation that requires advanced practice registered nurses and nurse practitioners to identify themselves to the public in Spanish. By using these translations, the healthcare community can better understand, collaborate, and connect, ultimately benefiting everyone involved and moving toward achieving health equity.

Footnotes

Declaration of conflicting interests

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

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Rubi Alva de Hickson

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The Appropriate Translation of the Nurse Practitioner Will Foster Health Equity