Lost in Translation
Nurses trained to be sensitive to cultural and linguistic differences
help improve access to care for non-English-speaking patients
By Heather World
August 25, 2004
As a child, Dorah Sanchez de Jeudy, RN, traveled from cotton fields in Texas to beet fields in Colorado and on to Oklahoma and Ohio, moving with her family and other migrant workers who spoke little or no English.
“I would end up going to the clinics with some of the women,” said Sanchez de Jeudy, who recently retired as the tuberculosis elimination nurse at the South Texas Health Care System in Harlingen. There, she would interpret the physicians’ questions and the women’s answers. “A lot of things I didn’t comprehend. I was just a child.”
What she did comprehend was both English and Spanish and the differences between American and Hispanic cultures. She interpreted for the workers during visits to clinics. She changed their dressings and translated the directions for their medications.
“I think that’s what encouraged me to go into nursing,” Sanchez de Jeudy said, adding that her parents’ emphasis on getting a good education helped, too.
According to the U.S. Census, the foreign-born population grew from 10 million in 1970 to 28 million in 2000. Previously, most immigrants came from Europe, but since 1970, the percentage of immigrants from Asia and Latin America has steadily grown. In 2000, the bureau estimated that Asians accounted for one-quarter of foreign-born residents and Latin America accounted for nearly half.
Since civil rights legislation in the 1960s, the American medical system has tried to accommodate patients who don’t speak English, but Sanchez de Jeudy and other nurses who serve non-native English speakers know that speaking a foreign language is only half of medical translation. To better serve such patients, the nurse also must cross a cultural divide and recognize different notions of medicine and the nature of illness.
At the same time, the nurse represents a medical establishment that has its own language, said Faye Gary, RN, PhD, FAAN, executive consultant to the minority fellowship program at the American Nurses Association.
“You talk about IV and bed rest. All of these terms might seem simple, but have no meaning outside of health care,” she said. “That language has to be translated into a language the patient understands within their culture.”
Nurses are usually the first point of significant contact for patients, and they may subsequently oversee that person’s health care team, said Gayle Tang, director of Kaiser Permanente’s National Linguistic and Cultural Programs. “We need to be the role model and be more knowledgeable to facilitate understanding,” she said.
Tang helps Kaiser deliver “culturally and linguistically appropriate care” to its 8 million members. She trains key regional leaders to develop systems and materials for patients who don’t speak English fluently, helping them make appointments, find interpreters, receive written instructions in the appropriate language, and get referrals to other providers.
Twenty years ago when Tang started at Kaiser, the organization had no such system in place. She was sometimes pulled aside as an impromptu interpreter. Although she didn’t mind the demand on her time, she did fret over seeing patients in the late stages of diseases that could have been prevented had they had more adequate access to health care.
“It was so evident as soon as I set foot into nursing that our diverse population is not able to access the system, and when they do, they don’t always get care and services that are meaningful,” she said. “When you have those barriers, patients cannot adhere to treatment.”
Too often, she saw patients labeled as noncompliant or indecisive when the real problem was in translation and a lack of understanding about cultural differences.
Workplace programs like Kaiser’s are mirrored in the academic world in places like the University of San Diego, which offers a family nurse practitioner track with a specialization in Hispanic health care. The track trains nurses to work specifically with vulnerable Hispanic populations like migrant workers and their families.
Cultural classes
Trang Kay, RN, MSN, became a family nurse practitioner through the program.
“We learned a lot of cultural beliefs as well as issues we may face working in border cities,” she said. For her specialization, she took classes about other cultures. She watched videos of medical interpretation to see the importance of translating exactly what a patient says rather than summarizing it in a Western way.
This can be a challenge, Kay said. Someone might say she is sick because someone made her jealous and the envy has caused a mass in the stomach, for example.
In her position at the San Ysidro Health Center south of San Diego, Trang sees patients who have a connection to Mexico. The proximity of Mexico means patients can self-medicate at pharmacies south of the border, which are considerably more lax than their U.S. counterparts in dispensing medicines.
“We explain that you can’t just treat yourself,” she said. “A lot of times, it’s the medication that’s causing them to feel ill.”
Many of her patients do not see the point in maintenance health care until she is able to point to specific examples.
“A whopping blood pressure still needs to be controlled even if you don’t feel the symptoms,” she said.
Her patients often live in extended families who all become involved in the care, which can help, especially if a nurse wants to emphasize the potential devastation of a long-term illness that could be treated, Kay said.
At other times, keeping the family separate from patients is important. Kay has noticed that some Hispanic men, for example, give more detailed answers when they are questioned alone.
From her training and from her work, Kay has found herself surprised at the array of health care systems and beliefs in the world. Studying medicine along with different cultures was effective, she said.
“You bring all that together and try to be as open-minded as possible,” she said.
Ninety percent of Sanchez de Jeudy’s clientele speak Spanish, she said. Many come from Mexico and have different beliefs about medicine and disease.
Some do not understand why they must wear a mask or isolate themselves while others stop taking medications as soon as they feel better. Some assume TB is just a bad cold, treatable by dressing warmly and avoiding cold drinks.
Sanchez de Jeudy knows dismissing those beliefs would be a mistake.
“When you do that, they totally shut off and won’t listen to you,” she said.
Appreciating differences
For Joy Guideng, RN, director of cardiovascular services at University Medical Center in Las Vegas, years of experience have made her more sensitive not just to cultural differences, but to religious and personal differences as well.
She estimates that 90% of the care she gives patients is education, which requires sensitivity and an adroit use of general questions. Instead of recommending birth control, she might ask if a patient has even heard of it and would like information.
“From that information, we get what they know and what they don’t, and what they’re willing to take from us,” she said.
Guideng speaks Tagalog, the language of the Philippines, as do many of her colleagues. The staff has designated Spanish speakers who interpret as well, she said. In the past, a nurse might grab anyone on staff who spoke Spanish to translate, Guideng said, but now interpreters go through training that also teaches limitations on what can be said and ways to communicate effectively.
For other patients, the nurses have a conference phone line they use to get a certified interpreter for whatever language is needed.
Nurses can take classes, focus on empathy, or immerse themselves in other cultures, but those who have spent a great deal of time explaining the importance of following physicians’ orders only to see those orders ignored can feel frustrated.
“It’s not for us to judge what is good and what is bad,” Tang said. “It’s for us to devise strategies to provide the best care for the patient.”