Publication: Journal of Cultural Diversity
Date published:
Language: English
PMID: 38581
ISSN: 10715568
Journal code: JOCD

As the population grows more ethnically diverse in the United States (US), health care providers are increasingly challenged to communicate with patients who have limited proficiency in English. Recent surveys of the US population have found that approximately 16% of persons over the age of 5 years do not speak English at home, of whom 50% speak Spanish. Half of those individuals report limited to no proficiency in English (US Census Bureau, 2000). Barriers to communication can significantly impact a patient's ability to provide informed consent for treatment, get their needs /problems addressed by health care providers, comply with medical management directives, and / or receive safe competent care during hospitalization (Adrulis, Goodman, & Pryor, 2002; Apter, Reisine, Affleck, Barrowa, & ZuWallack, 1998; Baker, Parker, Williams, Coates, & Pitkin, 1996; Carrasquillo, Orav, Brennan, & Burstin, 1999; Flores, 2005; Ramírez, Engel, & Tang, 2008; Timmins, 2002)

Past surveys or health care providers have found that few clinicians in outpatient settings access interpretive services which are available within their organization for patients with limited English proficiency (Baker et al., 1996; Baker, Hayes, & Fortier, 1998; Hampers, Cha, Gutglass, Binns, & Krug, 1999; Jacobs, Shepard, Suaya, & Stone, 2004; Phokeo & Hyman, 2007; Ramírez et al., 2008; Vandervort & Melkus, 2003). The infrequent use of interpretive services occurred despite small numbers of providers who were fluent in Spanish, the most common language spoken by patients with limited English proficiency (Vandervort & Melkus). It is not known if interpretive services are also infrequently accessed by health care providers during inpatient admissions.

Anecdotal information at our institution indicated the use of inpatient interpretive services was low. Whether this was related to a lack of patients requiring interpretive services, interpretive services being met by health care providers with translation skills, and / or a lack of health care provider awareness of interpretive services available within the health system was not known.

The purpose of this study was to determine the number of hospitalized patients who have limited English proficiency, with a non-English primary language and the number of inpatient nursing staff with communication skills in languages other than English, and to discover if nursing staffnave knowledge of interpretive services available within the institution.


This study was conducted in a 394 bed communitybased hospital located in the greater metropolitan area of a large city, in the Southeastern region or the United States. The types of services provided are comprehensive inpatient and outpatient health care services which include Oncology, Orthopedics, Heart and Vascular, General Medicine, General Surgery, Deliveries, Radiology, Rehabilitation, Pediatrics, Emergency Services, Wound Care, Stroke and Bariatrics. In this community hospital, the number of Emergency Department visits in a year is equivalent to 56,000 and the number of deliveries in a year is 6,400. Approval was obtained from the institution's investigational review board prior to data collection.

Study Design: An exploratory-descriptive study design was used to identify the languages hospitalized patients and nurses are comfortable using when communicating about health care needs. The dependant variables were the number and types of non-English languages spoken by patients and nursing staff and nursing staff knowledge of available interpretive services.

Sample Selection: A convenience sample of hospitalized patients and nursing staff were used for this study. Inclusion criteria for patients were: age > 18 years; identified themselves during the hospital admission process as not comfortable communicating health care needs in English; and were accompanied by a family member or friend during admission who spoke English and could communicate verbally with the patient. Patients who were physiologically unstable patients or those with severe pain or distress were excluded. Inclusion criteria for nursing staff included age > 18 years and employed at least 10 hours / week as a registered nurse or nurse's aide on an inpatient care unit the facility.

Study Procedure: During a one-week period, at the time patients were registered for admission to the hospital, the admitting clerk asked patients if they were comfortable communicating in English about their health care needs. Those patients who were not comfortable communicating in English were then asked to identify the language(s) that they are comfortable using for communicating about health care needs (Appendix 1). These questions were translated to the patient by the accompanying family member or friend who could speak English. Nursing staff were asked in an e-mail correspondence to complete and return a survey about their language skills (Appendix 1).

Data Analysis. Data were summarized with descriptive statistics. The number and types of languages spoken by both patients and nursing staff were categorized into verbal and written communication abilities. Languages spoken by patients and nursing staff were rank ordered. Nursing staff's knowledge of the interpretive resources available to hospital employees was determined as the percentage of nurses who could correctly identify interpretive resources.


A total of 821 patients and 216 nurses completed the surveys. Patient surveys were completed within a one week period, resulting in 821 patient surveys. Nursing staff surveys were completed within a two week period with 28% of the distributed surveys returned, resulting in 216 completed surveys. The majority of the nursing staff surveys were from registered nurses (83 %), with 11 % from certified nursing assistants (Table 1).

Results of the survey are described in the following 3 sections, each of which summarizes findings related to one of the three study questions:

1. What languages do patients feel comfortable using when communicating about their health care needs?


The vast majority of patients completing the survey were comfortable reading and speaking English (N=807, 98%). One patient respondent preferred to have written materials in another language, three respondents preferred speaking in a different language (< 1%), and 10 respondents preferred reading and speaking in another language (1%)· Of the languages listed as their preferences, Spanish was identified as the language of choice most often (5 of 14 respondents, 36%), with the next most common language listed being Gujarati (3 of 14 responses, 21%). Gujarati is the language spoken in the state of Gujarit, India. Other languages were identified as listed in Table 2.

2. What languages do nursing staff feel comfortable using when communicating with patients about their health care needs?

Twenty three of the 216 nursing staff respondents (11%) felt comfortable communicating with and teaching patients in a language other than English. Languages of Eroficiency were varied (Table 3), with the most common mguage being Spanish (12 respondents, 52%).

3. Are nursing staff knowledgeable of language interpretive resources available at Rex Healthcare?

The majority of nursing staff completing the survey were knowledgeable of tne various interpretive services available to them within the health system (Table 4). When asked about the frequency of their use of the phone service or an interpreter use in the past one month, 87% and 73% respectively said they had not used any interpretive services. Once a month use of interpretive services was reported by 22% of the survey respondents for use of an interpreter and 11% for use of the phone service within the past month. Four percent of staff surveyed reported at least once per week use of an interpreter.

Nursing staff were also asked to respond to whether the current interpretive services available within the health system met their patient care needs. Of the 192 respondents who completed this item, 63% felt the currently available services met their needs. Few individuals who reported that needs were not met provided any detail on why the interpretive services did not meet their needs. Reasons listed for not having their needs met included long wait times for interpreters, inconvenience of passing the phone back and forth between the nurse and patient when interpretive phone services were used, and poor availability of interpretive services when families are visiting.



One limitation to this study was that outpatients and emergency room patients were excluded. It is possible that language needs in those areas may be different from the sample of patients we studied. Another limitation was the length of time the patient surveys were conducted (one week), which may not have captured all of the language needs of patients attending our facility.


Based on the patient survey data, it would appear that there are very few (< 2 %) patients who come through the registration process at our facility who are not comfortable using English for communication. For those requiring translational services to meet their communication needs, Spanish is by far the most common language requirement (36 %).

Based on the 216 nursing staff respondents surveyed, it would appear that there are several staff (N=23) who feel comfortable communicating in a language other than English. Similar to the patients' surveyed, Spanish proficiency is by far the most common language skill possessed by nursing staff (52% of the 23 staff with language proficiency other than English). The survey also identified that while many nursing staff are aware of the variety of interpretive services available at our facility, some staff were unaware of the available services. The Diversity Committee incorporated the information on resources and types of interpretative services available to the hospital wide orientation.

The survey allowed us to obtain some suggestions as well. Both suggestions and names of staff who could read and speak other languages were forwarded to Interpretive Services Department. The results will help our organization to better plan for the types and frequency of interpretive services required by our patients. Further research on patients visiting Emergency Room Department maybe beneficial since it is possible the translational needs in that area are different particularly if the Emergency Department is used by large number patients as their "primary physician". Our survey was only completed on inpatients, whereas an Emergency Department population could potentially be very different in terms of language interpretive services needs.


Adrulis, D., Goodman, N., & Pryor, C. (2002). What a difference an interpreter can make - health care experiences of uninsured with limited English proficiency. Interpreter Health Care, 1-14.

Apter, A.J., Reisine, S.T., Affleck, G., Barrows, E., & ZuWallack, R.L. (1998). Adherence with twice daily dosing of inhaled steroids. Am J Respir Crû Care Med, 157, 1810-1817.

Baker, D., Hayes, R., & Fortier, J.P. (1998). Interpreter use and satisfaction with interpersonal aspects of care for Spanish speaking patients. Medical Care, 36, 1461-1470.

Baker, D., Parker, R., Williams, M., Coates, W., & Pitkin, K. (1996). Use and effectiveness of interpreters in an ER. JAMA 275, 783-788.

Carrasquillo, O., Orav, E., Brennan, T., & Burstin, H. (1999). Impact of language barriers on patient satisfaction in an ER. / Gen Intern Med, 14, 82-87.

Flores G. (2005). The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev, 62, 255-299.

Hampers,L., Cha, S., Gutglass, D., Binns, H, & Krug, S. (1999). Language barriers and resource utilization in a pediatrie ER. Fed., 103, 1253-1256.

Jacobs, E., Shepard, D., Suaya, J., & Stone, E. (2004). Overcoming language barriers in health care: costs and benefits of interpreter services, Am J Pub Health, 94, 866-868.

Karliner, S., Perez-Stable, E., & Gildengorin, G. (2004). The Language Divide: The Importance of Training in the Use of Interpreters for Outpatient Practice. / Gen Intern Med., 19, 175-183.

Phokeo, V. & Hyman, I. (2007). Provision of pharmaceutical care to patients with limited English proficiency. Am J Health-Sys Pharm, 64, 423-429.

Ramirez, D., Engel, K.G., & Tang, T.S. (2008). Language interpreter utilization in the emergency department setting: a clinical review. J Health Care Poor Underserved. 19(2), 352-62.

Timmins, C. (2002). Impact of language barriers on the health care of Latinos in the United States: A review of the literature and guidelines for practice. J Midwifery Women Health, 47 (2), 80-96.

US Census Bureau. (2000). The Hispanic population in the US. Current Population Report No. WE-R2. Washington, DC: US Federal Government Press.

Vandervort, E. & Melkus, G. (2003). Linguistic services in ambulatory clinics. J Transcult Nsg, 14(4), 358-366.

Author affiliation:


Author affiliation:

Deniz Ender, MLS, AHIP, is Medical Librarian, Learning and Organizational Effectiveness. Wanda Adams, BSN, RN, is Clinical Nurse Manager, Women's and Children's Service. Helen Horton, BSN, RN, is Clinical Nurse Educator, Cardiovascular Services/4 West Telemetry. Lou Ann Hobbs, MBA, SPHR, is HR Strategic Planning Consultant, Human Resources. Rebekah McLaurin, BS, is Clinical Development Specialist, Clinical Development Department. MaryClare K. Prasnikar, RN, MSN, CCRN, is Clinical Nurse Specialist Cardiovascular Services. Please address all correspondence to: Deniz Ender (Pl), MLS, AHlP, Rex Healthcare Library and Information Research Center, 4424 Lake Boone Trail, Raleigh, NC 27607. Phone: (919) 784-3032; Fax: (919) 784-1670;


The use of this website is subject to the following Terms of Use