Language barriers may be commonly recognized as threats to quality of care and patient safety, and hospitals routinely provide resources to overcome that barrier. But communication challenges can come in many forms and hospitals often are blind to them, leading to serious risks, one expert cautions.
Communication also can be hampered by cultural differences and varying levels of health literacy, notes Matthew Wynia, MD, MPH, director of the Center for Bioethics and Humanities at the University of Colorado in Aurora. Even the more commonly recognized language differences are not always effectively addressed, he says.
Wynia notes that communication failures were cited as root causes in 65% of sentinel events investigated by The Joint Commission in 2013, and some communication problems have nothing to do with obvious barriers such as speaking a foreign language.
In many cases, the clinician thinks he or she is communicating effectively, but is preventing the patient from providing important information by interrupting, cutting off statements, or leading the patient to address the physician’s hypothesis rather than simply explaining the problem and symptoms. (See the story in this issue for examples of communication breakdowns that affected the quality of care.)
“Studies have shown that if you don’t speak English or if you come from a background different than that of your doctors and nurses, you’re more likely to be the victim of an error,” Wynia says. “Many, many errors are the result of communication breakdowns and sometimes more than one communication error.”
Physicians should strive for one full minute of listening to the patient without interrupting, Wynia says. One minute may not seem long, but in fact, most physicians interrupt far sooner, he says. Similarly, clinicians should ask open-ended questions rather than yes and no questions. That means not asking, “Do you have any questions?” but instead asking, “What questions do you have?”
“That puts them at ease and tells them it’s okay if they have questions, that you expect them to have questions. You’re not perfunctorily asking if they have questions and expecting them to say no so you can walk out,” Wynia says. “I often tell them something like, ‘that was a lot of information and I don’t really expect you to absorb it all on the first go-round, so what questions do you have?’ You don’t want to put the onus on them to say they don’t understand.”
Low literacy, as it pertains to reading and writing overall, is an issue that clinicians are becoming more aware of, but health literacy is not yet as well recognized, Wynia says. Health literacy addresses an individual’s familiarity with health concepts and ability to understand information, particular directions for medication use and other self-care.
Clinicians live in a world of specialized language and information that is assumed generally known, he says, and they must consciously work to communicate with people for whom that is not the case.
“I’ve made the argument that every healthcare encounter is a cross-cultural encounter,” he says. “Most of us are not in healthcare, and when you enter healthcare you are entering a different culture. We use language in a way most people don’t, and we make assumptions about what people know and want.”
Even well-educated adults may have low health literacy, Wynia notes. Research has shown that low health literacy is associated with increased hospitalization, greater emergency care use, lower use of mammography, lower receipt of influenza vaccines, higher risk of mortality for seniors, and poorer overall health status among seniors, he says.
Wynia suggests looking for these red flags that could indicate a low literacy level, or other difficulties in understanding information:
- “I forgot my glasses, so I can’t read this right now.”
- “Let me bring this home so I can discuss it with my children.”
- Difficulty explaining medical concerns.
- Inability to name medications, or explain purpose or timing of administration.
- Clowning around, using humor.
- Becoming angry, demanding.
- Being passive, asking no questions.
Wynia advises more use of the “teach back” method with patients, in which the clinician asks the patient to repeat or explain the information provided. Do not ask, “Do you understand what I just explained?” because the patient is likely to say yes whether that is true or not. Instead, ask questions such as, “What will you tell your spouse or your daughter about your condition when you get home?” or, “Would you please explain that back to me so I can be sure I explained it correctly to you?”
To minimize the risk from communication issues, Wynia recommends using the Communication Climate Assessment Toolkit available through the Agency for Healthcare Research and Quality. It is available online at:
- Matthew Wynia, MD, MPH, Director, Center for Bioethics and Humanities, University of Colorado, Aurora. Email: firstname.lastname@example.org.
Communication Issues Hamper Quality of Care
These examples of how communication problems affected the quality of care for patients are provided by Matthew Wynia, MD, MPH, director of the Center for Bioethics and Humanities at the University of Colorado in Aurora:
- A woman, who reads at a fifth-grade level, gave birth, and in subsequent visits to her physician complained of persistent pain and bleeding. The doctor discussed how the problem can be addressed and she understood almost none of it, but the doctor was reassuring that there is a plan. She signed forms she hasn’t read, and later underwent a surgical procedure without fully understanding what was to be done. When she came out from anesthesia, a nurse said, “I hope you’re feeling OK after your hysterectomy,” and that was the first time she understood what procedure had been performed.
“Someone probably used that word with her at some point, and it certainly would have been in the documents, but she never understood until that point,” Wynia says. “The information may be very clear in the paperwork to you and me, but those things are written by lawyers and people are afraid to say they don’t understand it.”
- A Cuban man collapsed at his girlfriend’s door. She told first responders, then hospital clinicians, that he mentioned feeling “intoxicado.” The caregivers assumed that meant he was intoxicated and let that influence the diagnosis and treatment. It was not until two days later that the scan revealed he had a large epidural hemorrhage. He was left paralyzed. In fact, “intoxicado” has more complicated meaning in the Spanish language and Cuban culture, including the feeling of having been poisoned or feeling nauseated.
“His treatment would have been different if they had known he had an intracranial bleed right away, but they didn’t because they attributed his symptoms to intoxication until it was too late,” Wynia says. “This is why you cannot assume you know what someone is saying in another language. It is not even enough to simply have someone on staff who speaks that language. You need a trained translator who can understand the nuances of words and can help you understand information that may be vital to that person’s healthcare.”
The resulting lawsuit resulted in a settlement over $71 million. (More information on that case is available online at http://bit.ly/1xONNvK.)
- A man with stomach cancer refused chemotherapy after surgery and physicians never explored why, assuming it had something to do with his religion or culture. Three months later, his granddaughter visited and realized that the only reason he declined chemotherapy was that the doctors explained it would be provided through a surgically implanted port. He refused because such a port would prevent him from cleansing himself for daily prayers, but if the doctors had known that, they could have provided chemotherapy without the port. They never asked why he was refusing, and assumed religious or cultural objections to the chemotherapy itself.