FACT: Patients with limited English proficiency receive less self-care education.
Patient and family education—in particular, awareness of the importance of patient engagement and its impact on care outcomes—is gaining recognition as an important component of healthcare that is accountable. Important as it is for healthcare workers to engage effectively with patients, it is also imperative to recognize that poor outcomes are often the result of care disparities created by programs and services.
While none of us wants to think we or the healthcare systems we work for provide inequitable care, there are areas where we sometimes create disparities unknowingly. Patient and family education (PFE) is one of those areas. If a PFE program is designed to fully serve certain patients and families but not others, care inequities are created.
What is disparity?
Flores and Ngui (2006) define disparity in terms of race or ethnicity and language. They define racial or ethnic disparity as “any difference in health or healthcare among different racial/ethnic groups.” Language disparity, on the other hand, is defined as “any difference in health or healthcare between those whose primary language is English … and those whose primary language is not English and who are limited in English proﬁciency” (p. 1198). Limited English Proficiency, or LEP, is deﬁned as having a self-rated English-speaking ability of less than ‘‘very well.”
Equity is a term related to disparity but it has its own definition. Equity occurs when high or optimal health levels are achieved among groups of people by addressing and remediating avoidable differences in how those groups receive healthcare. Differences that most impact healthcare disparity include economic, social, environmental, and human characteristics.
Why linking PFE and disparity matters
There are two reasons disparity issues should be addressed along with patient and family education. First, language and racial/ethnic disparities significantly contribute to healthcare quality, safety issues, and errors (Flores & Ngui, 2006). While a variety of errors may occur, the error most relevant to patient education is that of omission. Omission errors contribute to a majority of medical errors and include both under- and non-utilization of care actions that result in adverse events and poor outcomes.
Patient and family education is effective only when there is transfer of knowledge. Both approach and strategy must take into account the health literacy of the patient and family, their language, and their English proficiency.
Reflect for a moment. One of your patients is ready to go home. His or her native language, and perhaps that of his or her family, is not English, although he or she may speak “some” English. Before discharge occurs, you need to review the patient’s follow-up care. Because the patient and family speak some English, you give them handouts that are in English, and you provide care instructions in English.
This is where disparity occurs. Plain and simple, using English to communicate with patients and families who have limited English proficiency about situations where they need to make decisions and act on self-care instructions places them at great disadvantage. Language and communication barriers result in greater risk for errors and misinformation.
Secondly, it is important to consider your nursing role to support knowledge transfer of learning goals. Omission of tools, resources, and methods crucial to knowledge transfer and learning—whether understanding a condition, acquiring skills needed for self-care management, or gaining ability to access and navigate health systems—negatively affects health outcomes. Other learning needs include acquisition of problem-solving skills, such as when to call a provider; how to determine the appropriate care setting for certain conditions; or what behaviors promote health or harm health.
LEP patients and families receive less PFE
Unequal treatment applies not only to direct medical care but also to when patients and families receive less of our time or fewer tools and resources to support learning. Learning is an exchange process where knowledge from the healthcare provider is transferred or handed off to the patient and/or to his or her family. The exchange is as effective—or ineffective—as the communication processes that support it.
Learning exchanges can be either formal or informal. Informal learning exchanges occur during teachable moments in a hospital or at a clinic visit. It is not uncommon for these informal learning exchanges to be inequitable because patients and families who have limited English proficiency often have less opportunity to interact with providers during these teachable moments—moments that have the potential to provide the most significant learning experiences.
Less time to ask questions or clarify misinformation means less time to practice skills and gain confidence in self-care management. Paying proper attention to education of racial- and ethnic-minority patients has been shown to improve knowledge, skills, and involvement in care decisions (IOM, 2003). Stereotyping, prejudice, and unconscious bias that negatively affect patient and family education result in confusing clinical information and affects decision-making, which lead to differences in treatment (Institute of Medicine [IOM], 2003).
One way to address disparities is by creating a comprehensive health-system approach to patient and family education. This starts with establishing a patient education program that has culturally relevant training tools. Ensure, for example, that simulation tools have patient-appropriate skin tones and that content used in lesson plans and support materials, such as handouts and ehealth tools, are culturally appropriate. Tools and resources should also reflect religious, spiritual, and cultural practices relevant to the knowledge and skills being taught because motivation for learning is greatest when there is congruence between teaching goals and a patient’s or family’s health beliefs.
In addition to reflecting religious and cultural practices, teaching materials such as handouts and educational videos must reflect the diversity of the community in which a health system exists, e.g., LGBT, veterans, seniors, or those with disabilities. Choosing simulation scenarios that are culturally meaningful is another way to show respect for diversity. For example, include various languages and types of families.
To be inclusive for same-sex families, use the term “parents” instead of “mother and father,” or consider using the term “caregiver” to accommodate a broader concept of who is providing care. For a PFE program to reduce disparities, a health system must ensure that content is translated into core languages, that a language resource structure and process support translation and interpretation of content in multiple languages, and that assistive or adaptive communication that promotes learning is available.
Connecting equity to PFE
A set of common measures is used to evaluate patient and family education programs. These include number of classes and attendees, attendee feedback, and satisfaction rating of the class. The next measurement level adds completion of education, pre- and post-assessments related to behavior change, comprehension, performance, and cost-benefit analysis. When possible, it is ideal to measure patient engagement and activation levels.
A more robust method is to relate outcome measures to patient and family education processes. Outcome measurements provided by the Institute for Health Triple Aim are most widely used (Berwick, 2008). They include satisfaction, readmission rates, emergency department (ED) visits, 48-hour returns to ED, and access to care. These measurements relate to other metrics, such as clinic visit no-shows or cancellations, follow-through with referrals (e.g., laboratory, radiology, or other appointments), self-care management efficacy, and discharge delays in inpatient settings.
Following is an example of how patient and family education effectiveness could relate to outcomes:
A class is offered on asthma care, and you are trying to see if it had any impact on patient visits to the emergency department. The class curriculum is presented via video and handouts. In comparing medical records of all attendees with emergency department visits, you notice that ED visits were reduced by 50 percent, a good outcome. A follow-up research study would yield further insights with regard to specific curriculum impact.
Applying the equity lens to your analysis tells another story. Analysis of two learner characteristics—language and race/ethnicity—may reveal if disparities exist in the patient population. In this instance, your data analysis might consist of how many class attendees had asthma-related ED visits.
The most common measures with reference points compare outcomes of white populations with outcomes of other races or ethnicities, patients who speak English with patients who speak other languages, and public versus private insurance. Depending on a particular health system’s focus in addressing equity, it may be important to analyze other population characteristics, such as patients (and their families) who are veterans or those who are gay, lesbian, bisexual, or transgender.
Analysis of data collected for the purpose of making decisions about equity of care should control for variables such as income and socioeconomic status, education levels, and severity of illness. Research data reveals that race and ethnicity are significant predictors of healthcare quality even after controlling for other factors (IOM, 2003).
PFE equity imperative
Patient and family education is often undervalued and under-utilized as a tool for reducing healthcare disparity. As a nurse and nursing leader, you need to recognize patient and family education as an opportunity to analyze and address equity of care, apply its tools organizationally, and measure its impact. I urge you to make a personal commitment to rethink your approach to patient and family education and to leverage PFE as a powerful tool to reduce healthcare disparities.
Lori C. Marshall, PhD, MSN, RN, administrator of Patient Family Education and Resources at Children’s Hospital Los Angeles, is the author of Mastering Patient & Family Education: A Healthcare Handbook for Success.
Berwick, D., Nolan, T., & Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27(3), 759-769. doi: 10.1377/hlthaff.27.3.759
Flores, G., & Ngui, E. (2006) Racial/ethnic disparities and patient safety. Pediatric Clinics of North America, 53, 1197–1215.
Institute of Medicine (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Smedley, B., Stith, A., & Nelson, A. (Editors). Washington, DC: The National Academies Press. doi:10.17226/10260.
Mastering Patient & Family Education: A Healthcare Handbook for Success, by Lori C. Marshall
ISBN-13: 9781940446301. Published by STTI, 2015
Price: US $59.95. Soft cover, 352 pages.