According to the US Census Bureau (2016-2015 American Community Survey), 65 million people in the United States in 2015 spoke a language other than English. Forty-one percent of respondents indicated that they spoke English at a level less than "very well" and would be classified as having limited English proficiency (LEP). Despite the inception of National Culturally and Linguistically Appropriate Services (CLAS) Health and Health Care Standards (Office of Minority Health, 2013) and health professions education guidelines for patient-centered and culturally and linguistically appropriate care (Institute of Medicine, 2003), research has shown that little has improved for patients with LEP (Office of Minority Health, 2013). Over the past decade, communication problems have been a root cause of a great majority of the serious adverse events reported to the Joint Commission's Sentinel Event Database. Patients with LEP are more likely than others to suffer physical harm when such errors occur (Agency for Healthcare Research and Quality [AHRQ], 2012; The Joint Commission, 2015), and they experience health disparities and poorer health outcomes (National Committee for Quality Assurance, 2016).
The growing number of patients with LEP makes it increasingly important that nurse faculty find effective methods for educating students in the CLAS standards. To that end, we devised an innovative instructional approach for our Transcultural Issues in Nursing course to help senior-level undergraduate nursing students learn how to provide more appropriate care for patients with LEP. Although LEP and CLAS standards were studied in this course and students had ample opportunity to observe how nurses interact with patients with LEP during their clinical work, research and anecdotal evidence suggested that this knowledge may not be adequately transferred to practice. Our goal was to create an experience that would not only inform but transform the views of students.
To better facilitate the transfer of knowledge, we adopted Kolb's (1984) definition of learning as "the process whereby knowledge is created through the transformation of experience" (p. 38). According to Kolb, the transformation of experience into usable knowledge takes place in a four-stage learning cycle: 1) concrete experience, whereby learners immerse themselves in new experiences, for example, providing nursing care to patients and observing others in the clinical environment; 2) reflective observation, where learners reflect on those experiences; 3) the abstract conceptualization phase, where learners form ideas and integrate their observations into action; and 4) the final active experimentation stage, where learners become actively involved in the experience and test previously introduced concepts (Kolb, 1984).
THE LEARNING STRATEGY
An initial poll of the 25 students indicated that most did not know much about LEP or CLAS standards. We designed the learning experience to incorporate the four stages of Kolb's experiential learning theory and further encourage active learning by involving the students in deciding how their learning about LEP, CLAS standards, and their impact on patients and health care would occur. As opposed to more traditional readings and/or PowerPoint presentations, we used videos and webinars to deliver the materials.
Students had already engaged in the concrete experience stage in a clinical setting, spending many hours working alongside nurses and other health care professionals. We thus began the experiential learning process with the second stage, reflective observation, asking students to think about a previous clinical experience involving patients with LEP and the recommendations of the CLAS standards. Each student posted a reflection on the Blackboard learning management system and commented on a peer's reflection. One, for instance, shared a situation in which the preceptor did not speak a patient's language, did not have time to obtain an interpreter, and did not fully complete the assessment of the patient's history during the admission process. Two students wrote about instances in which they felt patients were essentially ignored throughout the day because they did not speak English. Several noted instances in which basic nursing care was provided, but the students did not feel that "hourly rounding" was adequately performed, where the nurse would ask whether patients were in pain or needed anything. In some cases, students witnessed situations where a non-English-speaking patient was frightened but no one on the health care team took the time to find an interpreter to help assuage the patient's fear. During a class section, we encouraged further reflection and information gathering by discussing the students' feelings of helplessness during these experiences and their lack of knowledge about national CLAS standards. This exercise was intended not only to promote self-reflection but also to motivate the students to pursue increased knowledge on this topic.
To educate students, we used a student-selected webinar from the AHRQ highlighting the national CLAS standards, LEP, and the health disparities experienced by patients with LEP at the hands of health professionals. Students also watched short videos on YouTube depicting patients with LEP attempting to obtain health care. Although most students had personal experience in these types of situations, they had not witnessed an adverse event taking place because of them, so these videos were eye opening.
To engage students in active experimentation, we designed an assignment in which students were required to produce a brief narrative about the insights and knowledge they had gained during the reflective observation. Students used this opportunity for active collaboration. With minimal input from the faculty, they decided to produce a two-part video that would be informative and easily presentable to other students. The first part would depict a patient with LEP attempting to obtain health care in a facility that did not use CLAS standards; the second part would depict a situation where the same patient received appropriate linguistic and culturally sensitive care.
After discussing what was needed to produce the video and their own skills and experiences, students divided themselves into three groups: one to write the scenarios, one to perform and film the script, and one to research current data on LEP and CLAS standards regarding policies, numbers of LEP, and health care costs (financial and patient-related) to serve as a supplement to the content. The students arranged to use the nursing lab and met after class to film, edit, and create the video. They created realistic scenarios, placing appropriate signage and forms in the "patient's" native language around the "office," which advocated for providing patients with appropriate, qualified interpreters.
In the final stage, abstract conceptualization, we asked students to reflect on this experience and ways they could use it in their practice and write a short paper addressing what they learned, what went well, and how they might incorporate these ideas in similar situations. Among the learned information mentioned was a new recognition of the consequences of failing to communicate well with LEP individuals, including the risk of providing the wrong medication, inequalities that might result from lack of LEP services, and the possibility that patients might avoid seeking services. Students learned new ways to address these problems, especially how to access translation services, which they saw as the most effective way to avoid LEP-related issues. Nine students mentioned specific methods for obtaining translation, such as equipment or technologies that could be used or hiring a translator; three specifically mentioned problems with using family as translators rather than having a professional and dedicated translation service on hand.
Other new knowledge reported by students had to do with changing demographics, specifically the increase nationally in Spanish-speaking individuals and the local presence of a Polish-speaking population. Two students mentioned learning the definition of LEP, what qualifies someone as LEP, and the entitlements associated with LEP status. Four students directly addressed how they would do things differently after the project, indicating that they would try to provide better care for LEP individuals and seek out translation services when needed.
CONCLUSION
This project was a small-scale, evidence-based change project that offered an opportunity for students to integrate theoretical and practical applications and evidence-based standards for addressing the needs of patients with LEP within their current and future practice. It is our hope that students will take this knowledge and their newly gained ability to practice and present these materials in meaningful ways with their own peers in their RN practice. Given the overwhelmingly positive response indicated by our qualitative analysis of student feedback, we recommend repeating a similar intervention on a larger scale in a future study. We encourage nurse faculty to consider integrating similar active learning strategies given the seemingly successful nature of this particular multimodal educational intervention.
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