Improving Patient Safety Systems for Patients With Limited English Proficiency

Appendix A: Recommendations for Staff Training

Patient Safety Training for Nurses, Interpreters, and Frontline Staff

Train all staff, particularly frontline staff and interpreters, on the full spectrum of what constitutes a patient safety event (including near misses) and how to report them. Below are recommendations for training and educational sessions in this area:

• Include a focus on the definition of a patient safety event or medical error, as many interpreters and nonclinical frontline staff had a difficult time providing definitions of patient safety events and medical errors.
• Emphasize potential differences between patient safety events and adverse events and distinguish between actual errors and near misses.
• Provide data and specific examples of the ways limited-English-proficient (LEP) and culturally diverse patients are at greater risk for medical errors and patient safety events due to language and cultural barriers.
• Clarify roles and responsibilities for all clinical and nonclinical staff pertaining to reporting safety events and emphasize that all staff are responsible for reporting. Our study revealed that nonclinical staff might not report a patient safety event since they believe it is the responsibility of the clinicians on the care team.
• Incorporate instructions on how to use reporting systems to document and record medical errors and near misses.
• Using the Hospital Survey on Patient Safety Culture, evaluate whether training has made staff more likely to report an error. Available at: www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm.

Train Staff in Cultural Competence

Cultural competence training attempts to provide health care professionals with the tools and skills to communicate effectively across cultures. Some hospitals currently incorporate aspects of cultural competence into other trainings for clinicians and other staff. However, rarely, if ever, do these trainings focus on how cross-cultural issues, misunderstandings, and lack of respect for cultural beliefs and traditions, may lead to patient safety events among diverse populations.

In the recommendations below, we link cultural competence with recommendations to improve team communication given its relevance to both patient-staff interactions and staff-to-staff interactions. It is critical that training in cultural competence incorporate information on how issues related to cultural diversity or LEP may contribute to medical errors.

• Outline the goals and principles for what constitutes culturally competent care. It is crucial that all staff be trained with the same goals and principles.
• Teach a set of cross-cultural skills that will enable health care providers and staff to understand the impact of sociocultural factors on health and health care and be able to manage them more effectively in the clinical encounter. These skills could be applied to the care of any patient, regardless of background.
• Include an overview of key cultural beliefs and traditions that are associated with the most commonly served patient populations at the hospital. Ideally, these trainings could be co-led or led by members of interpreter services. Educating staff on common cultural and sociopolitical factors associated with the diverse populations served will provide a context in which to allow more open conversations between clinicians, staff, and patients.
• Include case examples of how cultural factors affect communication and medical errors.
• Include an overview of the diversity of staff and how this may relate to issues of power and hierarchy. Encourage appreciation, value, respect, understanding, and open communication.

“They will have to be trained in the key cross-cultural aspects of communication. For example, when patients nod, it doesn’t necessarily mean ‘I understand.’ It’s a nod that’s ‘pretending that I understand.’ So that would be a big factor for training” (Frontline, Interpreter).

Recommendations for Interpreter Training

In addition to basic training on medical interpreting and meeting International Medical Interpreter Association and National Council on Interpreting in Health Care standards of practice,* we recommend that training for interpreters include:

• Clearly outlined roles and responsibilities specifying when it is appropriate for interpreters to serve as cultural brokers or patient advocates. Consider using strategies to indicate a switching of roles (e.g., both hands up means interpreter moving from interpreter role to advocate role).
• Empowerment for interpreters to view themselves as critical members of the care team.
• Behavioral skills and communication tools to correct for errors related to clinician’s level of fluency.
• Guidance on how to report and document errors related to cultural factors (if reporting systems will be incorporating fields for the role of cultural factors in patient safety situations).

For additional information on standards for interpreters, see the Robert Wood Johnson Foundation’s Speaking Together Toolkit.

Train Staff on Using Interpreter Services

All staff need training on how to use interpreter services. Below is a summary of key points that such training should cover.

• Need for an interpreter:
  • Provide education and awareness about increased risks for LEP patients and the dangers associated with using nonqualified interpreters or trying to get by with inadequate language skills. Provide examples of how using nonqualified interpreters can have adverse effects on patient care.
• Hospital procedures related to language assistance:
  • Instruct trainees on how to inform patients that interpreter services are provided free of cost and they have a legal right to language services. Let trainees know that under no circumstances should minor children be used to interpret.
• Role of interpreters:
  • Train staff to understand the expanded role of interpreters as patient advocates and cultural brokers, and familiarize them with the code of ethics under which interpreters operate.
  • Address issues related to power and hierarchy. Provide strategies to create environments in which the interpreter feels like a valued member of the care team (e.g., introducing interpreters as part of the care team to patients, which can set a tone of inclusiveness).
• How to work with interpreters:
  • Teach trainees how to call for interpreters and how to explain to patients why they do not use friends or family members to interpret.
  • Emphasize the importance of professionalism — showing courtesy and respect — when working with interpreters and caring for LEP patients.
  • Instruct trainees on how to use structured communication skills (e.g., TeamSTEPPS® tools).
  • Inform both staff and interpreters that it is appropriate for interpreters to correct false fluency errors.
  • Verify language proficiency of all staff who want to converse with patients in languages other than English.
• Use of interpreter services:
  • Train providers on how to use available resources if an interpreter is not available for face-to-face interpreting. Encourage use of alternative services (e.g., video and phone).
  • Teach trainees how to access interpreters, scheduling in advance and as needed.
• Awareness of health literacy:
  • Train providers to avoid medical jargon and to use clear communication techniques for all patients, especially for LEP patients where the language can be an added barrier.

*Certification programs for interpreters have recently been developed. For more information see: the Certification Commission for Healthcare Interpreters and the National Board of Certification for Medical Interpreters.

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