For medical professionals working in hospitals, the daily effort to balance our patients’ personal and clinical care, paperwork, and the tangled web of hospital, state, and federal compliance takes its toll. It’s a complicated soup of evidence-based medicine and best practices, seasoned with patient and organizational quality requirements and measurements that are increasingly redefining multiple elements of care. Additionally, there is the human factor, involving our patients, their families, and the nurses who serve them.
Nobody likes being in the hospital. Despite this, I see a hospital as a place for happy beginnings, recovery, hope, and respect. Behind every surgical mask and pair of scrubs is a warm human being who is highly trained, empathetic, sympathetic, and dedicated to the patient’s full recovery.
Nurses work hard to achieve peak performance while remaining emotionally and intellectually focused. Our patients and their loved ones are managing a multitude of emotions over the patient’s well-being, and they need accurate, useful information, support, and comfort. If English is not their first language, we face additional obstacles in ensuring comprehension and compliance, which has a direct impact on recovery, readmissions, and patient satisfaction ratings. Simply, the more patients understand the importance of the role they play in their own recovery and longer-term wellness, the better it is for everyone involved.
Communication is more complex than language barriers alone. Culture, geography, gender, and patient age change the dynamic, as do the demographics of caretakers once patients have returned home.
Many hospitals have moved past old-fashioned videos and are now using interactive patient-engagement technology to deliver on-demand digital videos as part of their education programs, including features that allow nurses to build content into the patient’s condition-specific care plan. These systems also offer interactive capabilities, such as electronic documentation, detailing what programming the patient has viewed, in addition to simple testing to measure patient comprehension and retention. The nurse or physician can then meet with the patient and family for follow-up opportunities, ask and answer questions, and provide additional education or resources as required. All of this becomes part of the patient’s electronic medical record (EMR), moving toward mandates that will eventually link all care and recordkeeping digitally, and will provide concise documentation for reimbursement, compliance, and accreditation needs.
Additionally, these interactive capabilities can be used for service assistance and service recovery, as well as report generation and analysis for quality improvement. Leading hospitals are embracing multiculturalism in their patient-engagement communication outreach, providing on-screen information, direction, and educational programming in popular alternative languages, including Spanish, Russian, Mandarin, and a whole host of other tongues based on local demographics.
When patients are ill, their comprehension is already compromised. Stress, pain, fear, and lack of sleep exacerbate that disconnect, so when we can provide educational information and guidance in their native language, it improves comprehension for the patient and the caregivers, and increases their comfort level. Today, there are hundreds of educational programs that have been translated into foreign languages, as well as on-screen commands and prompts, and related follow-up testing, all conducted through the patient’s bedside phone and visually navigated on the television screen.
When this multicultural transition first gained momentum, it was often completed with alternative-language subtitles or voiceovers. Also, the programming often does not reflect cultural differences still apparent in ethnic communities, further devaluing the authenticity of the message and credibility, even if the information is accurate. In contrast, when the person delivering the message is a native speaker and is aware of cultural behaviors, norms, and practices, patient acceptance of the message improves dramatically.
These changes are more than just pragmatic. Having nurses hindered by language barriers reduces our effectiveness. The Joint Commission (formerly the Joint Commission on the Accreditation of Healthcare Organizations), the National Committee for Quality Assurance, and other ratings organizations are relying on hospitals to better involve patients in their own care and are surveying patients on their satisfaction levels. By making this effort, we’re saying to our patients and their families, “We recognize and respect your cultural differences.” That bridge also requires that we recognize different dialects and even regional variances, such as colloquialisms and slang.
To ensure improved understanding and enhanced compliance, hospitals are also turning to multilingual educational materials in simpler, more customized vehicles, such as PowerPoint presentations done in multiple languages and complemented with native-language voiceovers recorded by skilled translators. Another cultural trend well established within the Latino community is to use fotonovelas, which are photographs with copy bubbles created in multiple languages. Comic book-like illustrations are used as well. Some hospitals offer phone systems that automatically connect the patient or his/her family member to a translator or a multilingual menu, rather than having the patient wait until a translator is available to visit the room. These efforts drastically increase the patient’s adherence to the care plan.
There are a number of third-party content vendors offering video educational programming services, and in my travels, I have seen more than 400 health care titles in close to 30 languages. Once these and other customized programming are incorporated, they allow hospitals to offer 24/7 on-demand programming complemented by entertainment channels, relaxation channels, hospital information, Internet access, and other amenities offered in multiple languages.
Northridge Hospital Medical Center in Southern California has a large Hispanic population and many patients with low literacy rates. A 2004 survey that sampled 42% of Northridge’s maternity patients revealed health literacy challenges in deciphering, retaining, and using patient education information on labor, delivery, recovery, and infant care. Twenty-three percent of California adults lack basic literacy skills, according to 2003 (most current) statistics from the National Assessment of Adult Literacy. And a 2009 study from the University of California, Berkeley also revealed that 25%–33% of people in the area couldn’t speak English well or at all.
Northridge’s Perinatal Program Manager, Ruth Gonsoski, R.N.C.-O.B., C-E.F.M., M.S.N., also discovered that despite their best clinical efforts, the hospital’s maternity department was receiving low patient satisfaction scores related to questions like, “How well did you learn how to breast feed or bottle feed your baby”? Recognizing that they needed more practical tools to help patients make a successful transition from hospital to home, they searched for ways to improve educational proficiency. Additionally, Gonsoski knew there were common cultural myths involving care, such as patients’ belief that epidurals cause permanent back problems, privacy around breastfeeding, issues involving eye contact with male nurses and physicians, the use of herbs and home remedies that weren’t healthy for the pregnant mother or fetus, and more.
The hospital’s solution was to implement TeleHealth Service’s TIGR® interactive patient-education system, and to develop a directory of videos that met the language, literacy, and informational needs of Northridge patients. Their library addresses issues such as care of the newborn, breastfeeding, pain management, general health and wellness topics, diabetes, congestive heart failure, cancer, stroke, and other common conditions. Many of the titles are available in both English and Spanish.
Gonsoski, part of the Hospital’s centralized education department, led the effort to integrate multilingual videos and programming into maternity. In addition to Spanish-language videos and on-screen interactive navigation, they used a simple 10-question comprehension test to measure understanding. After completing the video, the patient was transferred to the comprehension test and prompted through the questions. This information then became part of their permanent electronic medical record, and posed opportunities for nurses to provide follow-up support. They also gave patients a Spanish-language post-partum package with materials such as booklets and magnetic refrigerator checklists.
Gonsoski says they’ve seen significant improvements in patient satisfaction scores since implementing these multilingual educational tools. Before the installation of TIGR, 46% of Northridge’s obstetric patients had trouble retaining critical information such as how to feed a baby or respond to an emergency. With the use of TIGR’s multisensory teaching method, retention has risen to 95%. By posing questions at the beginning and end of a video, Northridge nurses can determine the comprehension rate of their patients and can easily fill in the gaps. This resulted in their winning a nationwide Avatar 2007 Award for Most Improved Unit for Exemplary Service. Of the many videos that play each month at Northridge, infant care-oriented videos, such as infant CPR (in English and Spanish) and breastfeeding, are highly utilized. These videos have become so effective that they are now required elements of obstetric patients’ care plans.
Not only is this effort on focused cultural outreach improving results for patients, it provides an electronic record for ratings organizations to review and helps nurses feel better about their efforts and patient outcomes. It also frees nurses for more clinical functions. Hospitals don’t just want nurses trained to conduct tests and work through translators; they want nurses empowered to make a difference. These principles of adult learning are now being embraced throughout the industry.
As the synergistic worlds of health care technology, staff resources, and patient needs mesh with funding challenges, compliance mandates, and escalating quality requirements, one truth remains evident: the critical roles of technology and personal, face-to-face care will remain essential in today’s evolving health care world.