ADDRESSING THE NEED FOR IMPROVED COMMUNICATION WITH SPANISH-SPEAKING INDIVIDUALS AT A CHILDRENS HOSPITAL

ADDRESSING THE NEED FOR IMPROVED COMMUNICATION WITH SPANISH-SPEAKING INDIVIDUALS AT A CHILDRENS HOSPITAL Presented to Jane Schneider Assistant to the Chief Executive Officer A Hospital for Children Prepared by Michelle Whalen, Kathryn Haven, and Drew Yetter

Table of Contents Executive Summary...iii Introduction...1 Background Method of Study Research Criteria Findings...3 Assessment of the Problem Design of the Prototypes Assessment of the Prototypes Implementation...5 Conclusion...6 Appendix A Initial Assessment Questionnaire...7 Appendix B Initial Assessment Interview Questions...8 Appendix C- Tips Sheet Prototype...9 Appendix D- Informational Form Prototype...10 Appendix E- Prototype Assessment Interview Questions...11 Appendix F- Work Cited...12

Executive Summary Purpose The objective of this study was to improve communication between the nursing staff and Spanish-speaking individuals, particularly on the inpatient units. The project provides the Hospital for Children with two document prototypes that should be distributed to Spanish-speaking individuals upon check-in as needed. Method of Study Findings We originally planned to conduct the study in Unit 3E of the Hospital. Our group proposed to handout questionnaires and conduct interviews with nurses in the unit and parents of patients that were admitted. As you know, we encountered problems with obtaining the proper authorization to carry out these studies in the hospital and had to utilize other resources. We therefore consulted with nurses at a School for the Disabled, nursing students at the University of Delaware, and Spanish-speaking families in New Castle County and abroad. Our recommendations are based on the following research methods: Interviews with and questionnaires given to nurses at a School for the Disabled, nursing students at the University of Delaware. Interviews with Spanish-speaking individuals in the community and at the Western Family YMCA of Delaware. Analysis of Spanish for the School Nurse s Office, provided by the nurses at a School for the Disabled. Creation of document prototypes. Assessment of prototypes via follow-up interviews with initial interviewees and via e-mail with Costa Rican acquaintances of one of the group members. The research indicates that nurses, nursing students, and Spanish-speaking individuals would like to see additional forms of bilingual communication in the health care setting. In particular, they feel that, in addition to the existing 24-hour hotline, other communication products should be designed to cut down on many of the communication problems that arise between the nursing staff and Spanish-speaking individuals. It is essential for the communication products to be as basic and straightforward as possible, and for them to address the problem of illiteracy. Findings suggest that pictures be used and questions should be multiple-choice whenever possible. It is also important for the nursing staff to have an English version of the documents so that they can easily

understand the information being exchanged. And either a tape recording or a videotape should be included for situations in which the individual(s) cannot read or write. Recommendations Based on our findings, we recommend that: In addition to the current 24-hour language line, the hospital create at least two documents in both Spanish and English: a unit tips sheet and a form requesting information from the patient and/or his/her parents. The documents be placed at the front desk of inpatient units for nurses to distribute on an as-needed basis. The documents should only be used once it has been established that the patient and/or his/her parents prefer Spanish to English. Both documents be accompanied by a tape recording to be used if it is found that the individual cannot understand English and is unable to read and/or write Spanish. Each document should be altered to reflect the communication needs of each particular unit.

Introduction Background We are three University of Delaware seniors (Michelle Whalen, Kathryn Haven, and Drew Yetter) that have been assigned to complete a communication needs assessment for our Written Communications in Business class. The assignment entails an assessment of a communication problem within a particular organization and the creation of some communication product (i.e. a document, phone recording, etc.) that will help to solve the problem and thus allow the company to operate more efficiently. Based on our own personal experiences and educational backgrounds, we identified the Hospital for Children as an institution that could benefit from such a communication needs assessment. In particular, we find that there is an immediate need for improved communication between the nursing staff and Spanish-speaking individuals. The hospital s 24-hour language line is both useful and necessary, particularly in emergency situations, but it should no longer serve as the hospital s only form of bilingual communication. Using a third party phone line to communicate basic requests or ask basic questions makes Spanish-speaking individuals feel alienated and uncomfortable in an already-stressful situation. For the nursing staff, the language barrier is also time-consuming and frustrating in that it often takes several minutes to communicate one simple message. In addition to obvious frustration, such problems likely result in a marked decrease in service efficiency. To resolve these problems, this report presents findings, recommendations, and three prototypes of communication products that will help facilitate communication between the nursing staff and Spanish-speaking individuals. They include a tips sheet which will communicate basic unit guidelines to the patient and/or his/her parents, an informational form requesting basic information about the patient, and a taped recording of the contents of the documents. These products will benefit patients and their families, the nursing staff, and the hospital as a whole by helping to break down the inconvenient language barrier. It will save time, reduce frustration, and subsequently increase satisfaction for both Spanish-speaking individuals and the nursing staff. As the Spanish-speaking population continues to grow in the United States and the Wilmington area, so too does the number of hospital visits by Spanish-speaking individuals. It becomes increasingly necessary to immediately address this situation by creating bilingual communication products, such as the ones we recommend, in order to facilitate communication between hospital employees and the Spanish-speaking population. Method of Study

We conducted research in order to determine the appropriate content and design to develop complete and comprehensible bilingual communication products. After designing prototypes based on these findings, we assessed the product effectiveness. As stated earlier in the report, we revised our original proposal to include new audiences (including nurses at a School for the Disabled and UD nursing students) to interview and question for our research. We used the following research methods: Distribution of questionnaires to three nurses at the School for the Disabled, ten University of Delaware Nursing Students, and three friends and acquaintances of group members that are nurses. These questionnaires were also designed to assess the need for bilingual communication in the hospital setting and left room for suggestions for document content (See Appendix A). Interviewers also asked the individuals to verbally share any personal examples of their own experiences with Spanish-speaking individuals. Interviews with eight Spanish-speaking individuals at the Western Family YMCA of Delaware, as well as six Spanish-speaking friends and acquaintances in the Wilmington area, in order to assess the Spanish-speaking population s opinion regarding the need for improved bilingual communication in the health care setting. The questions were open-ended and allowed for individuals to share personal examples of problems they or someone they know may have had in communicating with the nursing staff in hospital (See Appendix B). Because some of those interviewed spoke both Spanish and English, we conducted half of the interviews in Spanish and the other half in English. Study Criteria Review of Spanish for the School Nurse s Office from the School for the Disabled in order to determine the appropriate document format and the type of information to include. Creation of the prototypes (See Appendices C and D). Follow-up interviews of nurses, nursing students, and Spanish-speaking individuals in the community in order to assess understanding and support/opposition, and leave room for improvement suggestions (See Appendix E). Also, similar interviews via e-mail with ten Costa Rican acquaintances of one group member ranging in age from 16 to 54. We sent them copies of the prototypes and asked them to answer the same questions interview questions. Our group used the research methods above to gather information concerning the features required to develop the most useful and effective communication product.

Content: What information is most commonly communicated to patients and their parents concerning their hospital stay? What information needs to be collected by the nursing staff when a patient is admitted? How should the documents begin and end? Should they include a welcome message and/or a closing message? What should these messages include? Format, Usability and Complexity: What document design elements should be used to ensure comprehension? How will they gain attention? Should the document include pictures? Should a cassette recording or video tape be included? What design elements should be included to ensure that the nursing staff can easily understand their contents and answers provided? Should the documents be in both English and Spanish? Should the documents be multiple-choice? Implementation: How will the new documents be introduced to the employees? Should they receive a memo describing the situation and explaining the products? Should a staff meeting be held in order to ensure that the staff understands the information? How will the documents be introduced to Spanish-speaking individuals? Should they be asked whether they prefer English or Spanish first? Findings Assessment of the Problem The nurses and nursing students interviewed showed a deep interest in bridging the language gap between themselves and Spanish-speaking individuals in the health care setting. Of the sixteen nurses and nursing students interviewed, only one, Victoria Smith, said that she has at least a basic grasp of the Spanish language. Each person said that a 24-hour language line is definitely a start, but that it is not enough in today s society, given the recent surge in the Spanish-speaking population of the United States. They all agreed that hospitals should incorporate various documents to facilitate communication between the nursing staff and Spanish-speaking individuals. While they cited everything from posters, brochures, and forms to videos, they said that a tips sheet, an informational form requesting important information, and even video cassettes would be the first step to breaking down the language barrier that makes effective service so difficult in the health care setting. In order for our group to create these documents, they provided examples of information commonly given to patients and their parents on an inpatient unit and questions that are typically asked by the nursing staff. The fourteen Spanish-speaking individuals interviewed also agreed that the lack of bilingual communication in the health care setting needs to be addressed. They all cited at least one negative hospital experience of their own or someone they know, blaming the combination of the individual s inability to understand English coupled with the nursing staff s inability to understand Spanish. Ann Marie Marco, a member of Delaware s Western Family YMCA, said that being unable to understand the nursing staff makes Spanish-speaking individuals feel ignorant, and that the frustration of trying to

communicate only adds stress to an already-stressful situation. She applauded the idea of a language hotline, but said that it should only be used in emergency situations. Basic information, she said, should be exchanged between the nursing staff and the parents on a one-on-one basis, as it would be embarrassing for a mother that is struggling with her English to be directed to a phone line only to be told, for example, not to throw out the diapers. All of those interviewed expressed a strong desire to see improvements in the near future regarding bilingual communication in hospitals. Design of the Prototypes Our group created a tips sheet and an informational form requesting information based on the results of the questionnaires and interviews, as well as the examples provided in Spanish for the School Nurse s Office. The documents meet the following criteria: Content: The tips sheet (See Appendix C) contains five basic messages that are typically communicated to parents and visitors on an inpatient unit in a children s hospital. The informational form is designed to allow the nursing staff to gather information about the patient and/or his/her parents (See Appendix D). It requests basic information such as names, phone numbers, symptoms, allergies, and medications. Both documents include a welcome message stating the hospital s name and the purpose of the documents, and a closing paragraph thanking the individual for their cooperation and offering any further help. Format, Usability and Complexity: The tips sheet says welcome in large, colorful letters across the top in order to gain attention. Each message is short and simple, and is accompanied by pictures in order to address illiteracy. The document font is black, 16-point Arial bold. The informational form contains seventeen multiple-choice and fill-in-the-blank questions. The fill-in-the-blank questions will only request names, times, sizes, phone numbers, allergies, and medications. Words are in 12-point Times New Roman font and, because the document is more formal, it does not contain pictures or colors. In order to assess whether the form was understood and completed thoroughly, the final question asks, Did you understand all of the questions and answer them completely? In order to assure that the nursing staff is able to understand the documents, the nursing staff will be given English versions. Because most questions on the form are multiple-choice, staff should have no trouble in transferring the information to the computer database. In addition, medications, names, and phone numbers should be easily understood by the nursing staff because such information,

including the names of prescription medications, is typically universal. However, we recommend that the front desk be equipped with a Spanish-English dictionary for instances in which what the patient/parent writes is not understood. Assessment of the Prototypes In order to test our prototypes, we conducted follow-up interviews with the initial sixteen nurses and nursing students and eight Spanish-speaking individuals. Four of the Spanishspeaking individuals were interviewed at the Western Family YMCA of Delaware, two at the School for the Disabled, and the remaining two at a group member s house. We gave all interviewees the English and Spanish versions of the prototypes and asked them to read through them. They were questioned about their understanding of the documents, whether they thought that they would be helpful, and whether they had any suggestions for improvement (See Appendix E). In addition, we sent the prototypes via e-mail to twelve of our Spanish-speaking acquaintances that live in Costa Rica, ranging in age from ages 16 to 54. We asked them to review to answer the same questions that we used in our interviews. The feedback that we received was very positive and optimistic. Everyone interviewed understood the information conveyed in the prototypes and agreed that they would be helpful in a health care setting. Many also suggested that the documents be in both Spanish and English, as opposed to one or the other, or that individuals at least be given a choice as to which language they prefer. For example, one interviewee, who was born and raised in the United States, said that it would be insulting for her to be handed a document in Spanish because her name and looks may indicate that she is of Latin American descent. Interviewees also expressed support for a video or cassette recording, as they would benefit illiterate Spanish-speaking individuals as well as the nursing staff. Nurses, nursing students, and Spanish-speaking individuals expressed universal support for the prototypes. Implementation Before any new communication products are implemented on hospital units, we feel that it is important to make the nursing staff aware of the change. For example, memos should be placed in staff mailboxes explaining the need for the products and briefly explaining their content. If possible, staff meetings should be held in order to inform staff about the products, ensure their comprehension of the information conveyed in the products, and offer any suggestions on how they may be improved. The meeting may also include a brief workshop in which staff can test the prototypes. After the nursing staff is made aware of the change, the documents should be placed at the unit s front desk. There should be at least one master copy in English of each document to which staff can refer. When a new patient is admitted, nurses should go about their normal routine in exchanging information with the patient and/or his/her parents.

If it is determined that the individual is having trouble communicating in English, the nursing staff can ask if they prefer English or Spanish. By giving the individual a choice, and not automatically assuming that the person prefers to communicate in Spanish, staff will not be insulting the individual. If the individual says that they prefer Spanish, they should be given both documents and asked to complete the informational form. If they then have difficulty filling in the form, we recommend the creation of a video or cassette recording in both Spanish and English to help complete the form to the best of their ability. In a worst-case scenario, staff can refer to a Spanish-English dictionary, or can call the existing language line. Conclusion After completing our research, we are highly optimistic that our findings can benefit the. Hospital for Children. We feel that the continuous increase in the Spanish-speaking population in the United States is making it more and more important that health care institutions address the need for improved bilingual communication. While 24-hour language lines are an obvious step in the right direction, there is an immediate need to build on that stepping stone. Documents such as the prototypes we have developed should become part of the hospital s ordinary procedure. We hope that our research will help set the foundation for future large-scale change at the Hospital for Children.

Appendix A - Initial Assessment Questionnaire Communication in the Health Care Setting 1. Are you fluent in Spanish? YES NO 2. Have you experienced problems or heard of problems with communicating messages to Spanish-speaking individuals in a hospital setting? YES NO 3. Do you find that a 24-hour language line is a useful way of addressing bi-lingual communication problems? YES NO 4. Do you feel that a hotline is the most efficient in addressing bi-lingual communication problems and no written product is necessary? YES NO 5. What are the most common phrases/questions that you feel are communicated to patients and their parents by the nursing staff in a children s hospital when admitted overnight? 6. Do you think that a tips sheet that translates unit guidelines from English to Spanish (i.e. Dial 9 to make an outside call ) would be a helpful tool in nursing staff s communication? YES NO 7. Do you think that an informational form should be created that requests typical information provided by patients/parents on an inpatient unit (i.e. symptoms, allergies, etc.)? YES NO 8. Do you find that illiteracy is a problem that needs to be addressed? YES NO

Appendix B - Initial Assessment Interview Questions 1. Have you or anyone you know ever had trouble communicating in a hospital setting? If so, please provide examples. 2. Do you feel that hospitals have adequately addressed the need for bilingual communication? Please explain. 3. What do you feel should be done to help address the apparent lack of effective bilingual communication in the health care setting? 4. Do you feel that a 24-hour language line would be a useful resource for hospital staff and Spanish-speaking individuals? 5. Is there a need for other forms of bilingual communication in the hospital setting? 6. Would you feel more comfortable if you were given the opportunity to receive documents written in Spanish? 7. Do you feel that improving communication between Spanish-speaking individuals and the nursing staff at hospitals would yield positive results? Explain.

Appendix C - Tips Sheet Prototype Esta es una guía que ha sido diseñada para que su experiencia aquí en el Hospital para Niños Alfred I. dupont sea conveniente. No boten los pañales Hay una cama plegable Marquen el #9 para en el basurero en el cuarto para los hacer una llamada padres al exterior Solo los padres del paciente pueden pasar la noche Su enfermera se llama:

Gracias por su cooperación y déjenos saber si le podemos ayudar o si tienen alguna pregunta o preocupación. This is a guide that has been designed to make your experience here at the Alfred I. dupont Hospital for Children as convenient as possible. Don t throw out There is a cot in Dial #9 to place the diapers the room for parents an outside call to use Only the patient s parents can stay the night Your nurse s name is:

Thank you for your cooperation and let us know if we can help you in any way or if you have any questions or concerns. Appendix D - Informational Form Prototype FORMULARIO DE INFORMACIÓN Para poder servirle mejor aquí en el Hospital para Niños Alfred I. dupont, necesitamos realizar unas preguntas importantes. Favor de completar todo el formulario. 1. Cómo se llama el paciente? 2. Cuál es su nombre completo como encargado? 3. Cuál es su relación con el paciente? a) madre b) padre c) otra: 4. Cuál es su número de teléfono? Casa ( ) - Emergencia ( ) - 5. Tiene el paciente alguna(s) alergia(s) Sí No 6. Cuáles alergias? 7. Está usando el paciente algún tipo de medicamento? Sí No 8. Cuáles medicamentos? 9. Cuántas veces al día toma los medicamentos? 10. Cuándo fue la última vez que tomó los medicamentos? : AM PM 11. Cómo se llama su médico de familia? 12. Cuáles síntomas presenta el paciente (puede marcar todas)? a) diarrea b) estreñimiento c) vómito d) fiebre/calentura e) escalofríos f) descoloramiento g) tos h) estornudo i) falta de apetito j) otra(s): 13. A que hora fue la última vez que el paciente comió? : AM PM 14. Qué comió? a) leche a pecho b) comida sólida c) fórmula marca 15. Aproximadamente cuánto comió? onzas 16. El paciente usa pañales? Sí No Cuál talla? 17. Usted entendió todas las preguntas y las contestó completamente? Sí No

Gracias por su valiosa ayuda y le estaremos notificando si tenemos alguna otra pregunta o interés. Igual déjenos saber si le podemos ayudar en cualquier manera. Estamos aquí para hacer que tenga una buena experiencia aquí en el Hospital para Niños A.I. dupont. INFORMATIONAL FORM In order to better serve you here at the Alfred I. dupont Hospital for Children, we need you to answer some important questions. Please complete the entire form. 1. What is the patient s name? 2. What is your complete name? 3. What is your relation to the patient? a) mother b) father c) other: 4. What is your telephone number? House ( ) - Emergency ( ) - 5. Does the patient have any allergies? Yes No 6. What are his/her allergies? 7. Does the patient use any medications? Yes No 8. Which medications does the patient use? 9. How often does the patient take their medication? 10. When is the last time that he/she took his/her medication? : AM PM 11. What is the name of your family doctor? 1. Which symptoms is the patient exhibiting (please mark all)? a) diarrhea b) constipation c) vomiting d) fever e) chills f) discoloration g) coughing h) sneezing i) lack of appetite j) other(s): 13. When did the patient last eat? : AM PM 14. What did the patient last eat? a) breast milk b) solid food c) formula brand 15. Approximately how much did the patient last eat? ounces 16. Does the patient use diapers? Yes No What size diapers? 17. Did you understand and answer all of the questions? Yes No

Thank you for your generous help and we will notify you if we have any other questions or concerns. Also, please let us know if we can help you in any way. We are here to assure you that you have a good experience here at the Alfred I. dupont Hospital for Children. Appendix E Prototype Assessment Interview Questions 1. Did you understand the messages conveyed in the tips sheet? 2. Did you understand the informational form? 3. Do you feel that the documents are appropriately designed given their purpose? 4. Do you think that the content of the documents is sufficient? 5. Do you have any suggestions on how either of the documents may be improved upon? 6. Do you think that these documents should be accompanied by any other type of communication product (i.e. poster, video, cassette recording)? Why or why not? 7. Do you think that the documents should replace or accompany a 24-hour language line? Why? 8. Do you feel that the documents will help improve communication between Spanishspeaking individuals and the nursing staff in a hospital setting?

Appendix F - Work Cited Thuro, Barbara. Spanish for the School Nurse s Office. Vista, California: Ammie Enterprises, 1991.