Nursing students learn to balance language translation with legal rules

Nursing students learn to balance language translation with legal rules

Members of the health care work force are presented with a dizzying array of challenges in treating patients. Bilingual nurses, doctors and allied health professionals have an additional layer of moral challenge - are they legally able to speak to their patients in a second language?

Students from East Carolina University's College of Nursing are learning firsthand the complications that come from speaking a second language in a health care setting, and the legal ramifications of overextending their qualifications.

Lindsay Gonzalez, a fourth semester student from Fuquay-Varina, assisted Dr. Liz Mizelle, an assistant professor of nursing, with Mizelle's community service event. Mizelle is working to find ways to prevent heat injuries in those working in the agricultural sector in North Carolina.

During one visit, Mizelle and her team found out that one of the workers was extremely allergic to bee stings, which is an inconvenient reality for someone working on a farm where bees pollinate crops. Gonzalez made the 45-minute trip from Greenville to deliver a potentially life-saving dose of epinephrine that the worker could use if ever stung and as importantly, her translation of how to use the injector in Spanish.

"We spoke in Spanish, and I translated how to administer epinephrine, and from there we used the teach-back method and they showed us that they knew that how to use it," Gonzalez said.

Gonzalez said it was fun to engage with patients outside of a clinical setting and use her bilingual skills to make a real difference in a person's life, but it was still challenging to translate complex medical terminology into more accessible, everyday language.

Sara Santibanez used her Spanish skills to add an additional layer of understanding to Mizelle's research on farm workers' levels of hydration, to determine if hydration backpacks could prevent acute kidney injuries and other conditions.

"I did peer review of materials for the workers to read," Santibanez said, which required her to translate medical jargon into wording accessible for farmworkers.

Legal Responsibility

The challenge that Gonzalez and Santibanez have struggled with is finding the right balance between being conversational, and extending basic human kindness, and crossing a legal line by filling the role of medical translator, a task neither are yet qualified to take on.

Federal law requires health care providers who receive federal funding to provide translation services from a certified medical translator. The complexity of medical terminology, and the risk of miscommunicating crucial health information to patients who don't speak English, requires a lengthy and expensive training program for multilingual people.

The balance is delicate, and Gonzalez and Santibanez said that as student nurses in clinical settings, they had to tell the nurses and doctors whom they trained with that they couldn't risk everyone's license to practice by translating, even if they knew how.

"I remember being on an OB floor and the moment I stepped on there, a nurse pointed at me and asked, 'Do you speak Spanish?' I said yes, but it was my first day in second semester and we hadn't really talked about being safe and speaking Spanish because there's not really a course," Gonzalez said. "How do I know what is safer and what is not? How do I know, in Spanish, the difference between 'how are you doing' versus 'how is this epidural block doing?' So, what is my boundary? There's not a clear line."

Gonzalez said she ended up making a difficult, and uncomfortable, decision - she told the nurse that she wasn't qualified to translate. The MARTTI (My Accessible Real-Time Trusted Interpreter) system used for telehealth translation services started working two minutes later and provided a legal translation for the patient and medical staff.

"I'm glad that I had the courage to speak up. I can't imagine how I could have drastically changed her situation," Gonzalez said. "Sometimes I feel kind of helpless, especially if I have somebody I'm working with and they speak Spanish, but I'm not certified."

Dr. Kim Larson, a professor of nursing who has led groups of students for learning experiences in Central America for years, said future nurses who are bilingual and bicultural, such as Gonzalez and Santibanez, are important members of the health care team for Spanish-speaking individuals and their families.

"They can provide comfort and clarity on the nursing plan of care, and answer questions or find answers to questions the person or family may have about their care. I know this from my work with the Peace Corps in Honduras, Central America and at a migrant health center in North Carolina serving farmworkers from Mexico," Larson said.

Larson stressed, however, that she - and soon Gonzalez and Santibanez - are nurses, not translators, and their focus is on providing the best care, regardless of how the care plan is conveyed to patients and their caregivers.

Santibanez said she hopes that one day nursing schools can integrate language training into coursework so students can be certified as medical translators before graduation, a skill that would make new graduates more marketable, and more valuable to the medical communities they will join.

"It's really expensive to get certified in medical Spanish. But the hospital where I'm going to work over the next four months has a program for students or new grads. You have to learn Spanish and take a test and if you pass you are legally able practice speaking Spanish in a hospital setting," Gonzalez said.

Both students' parents are originally from Mexico, but both are firmly North Carolinian. Santibanez is originally from Columbia in Tyrell County, and Gonzalez is from Fuquay-Varina. When they graduate in December both say they will return to their homes, where they know their skills as bilingual nurses are desperately needed.

The (Complex) Need is Great

The challenges in translation aren't just between two languages; differences in culture and the way a language is used by different groups of speakers can pose problems, even for native speakers.

"I went to a patient's room, she wasn't my patient, she was Hispanic and only spoke Spanish. The nurse was having trouble communicating and I said, 'Hi, do you need anything' in Spanish and she looked at me like 'you saved me,'" Santibanez said.

Mizelle said that she's not aware of many nurses who have been certified to be medical translators, which leaves a huge gap in caring for the person, not just a medical condition.

"Bilingual nurses can speak in non-English languages when providing routine care. Although technology and resources have advanced, patients still tend to receive less information about their medication and health status when interpreters are needed, just because of how long it takes to translate and back translate," Mizelle said.

Mizelle said translators are just as important for a patient's loved ones, and long-term caregivers.

"I remember one patient whose wife stayed by the patient's side for days on end. She spoke a little English but they both primarily spoke Spanish. With a Spanish-English bilingual nurse caring for him, the wife was comfortable enough to leave to go home, to take care of herself, before returning," Mizelle said.

Just speaking Spanish in a clinical care setting isn't enough these days. The multi-ethnic and multilingual reality of even rural North Carolina means that communication with patients will continue to be a challenge for nurses.

"If I could go back, I would try to learn another language, maybe ASL (American Sign Language). Language is beautiful; it's a challenge that I'm willing to take. Duolingo - I'm coming for you," Gonzalez said.

Julio Maldonado, ECU Health's director of hospitality and language access services, said translation is a pressing consideration in the system's clinical spaces.

"We have a total of 32 interpreters across our system, including the academic practice at the Brody School of Medicine, and leaders who are also interpreters," Maldonado said. "We have about 300 access points for MARTTI across our enterprise - in hospitals, clinics and ECU academic practice - and we average 82,000 video and phone remote interpretation minutes per month."

Most hospitals have translation devices available for members of the care team to speak with patients, and there are new HIPPA-approved handheld translation devices that resemble a small cellphone, but have mixed success. Gonzalez said the translation services are suitable when there is no other option, but they can be clunky and lack the humanness that gives patients a sense of trust in their caregivers.

Santibanez agreed that the in-room translation services are improving because they have a video component, but they still lack the ability of a human in the room to pick up on non-verbal cues and make the patient more comfortable with the care team.

"Simple questions like, 'How are you doing?' make the patient feel at ease with the provider, and show you if they are progressing," Santibanez said.

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