Cultural and Linguistic Competency Toolbox

Quick Primer

What is cultural and linguistic competency?

Cultural and linguistic competency in healthcare refers to the ability to successfully communicate and provide care to patients with diverse beliefs, backgrounds, and values, thereby building understanding and trust between provider and patient. Culturally and linguistically competent providers and organizations actively adapt delivery of care to meet patients’ cultural, linguistic and social needs.

Why is cultural competency important?

Think about the changing landscape of the U.S. population. Although non-Hispanic Whites currently comprise the largest segment of the U.S. population, racial and ethnic minority populations are growing steadily.  Already, racial and ethnic minorities outnumber Whites in four states (Hawaii, California, New Mexico, and Texas), as well as the District of Columbia, the Virgin Islands, and Puerto Rico. The U.S. is projected to become a majority-minority country by 2043, with the greatest growth projected for multiracial populations (176%), Asians (93%) and Hispanics (86%).  The number of minorities enrolled in Medicare will increase based on the projection that one-third of the population age 65 and over will be people of color by 2040, and the need for culturally appropriate healthcare will increase accordingly.

One-third of the population age 65 and over will be people of color by 2040.

A concern is that minorities are underrepresented in the medical professions. Minorities make up fewer than 30% of practicing nurses and 23% of nurse practitioners. There is a similar imbalance among physicians. African Americans and Hispanics – the two largest minority groups – together make up 32% of the U.S. population but only 11% of active physicians. Although the number of students entering medical school increased in 2020 and applicants for 2021 has risen sharply, underrepresented groups have made only modest gains in medical school enrollment.

These statistics mean that most of time, minority people are receiving treatment from physicians and nurses who have a different cultural background from their own, and who may not speak the same language. When patients and providers do not share the same background, they may have vastly different expectations of the provider-patient relationship. They may also have conflicting understandings of the causes of health problems, the kinds of treatments that are possible or appropriate, and the role of family members in decision-making. The resulting misunderstandings can have serious health and safety consequences.

When healthcare providers and organizations provide more culturally competent care, they improve their ability to care for the people they serve and contribute to better health outcomes.

Most of time, minority people are receiving treatment from physicians and nurses who have a different cultural background from their own, and who may not speak the same language.

What does a culturally competent provider do?

The key components of cultural competence are important in every clinical encounter, and become even more essential to communication in situations where the provider and patient do not share the same cultural background.  A culturally competent provider is one who:

• Establishes a relationship of trust and mutual respect with the patient
• Is willing to have an open and honest two-way dialogue with the patient about their health
• Questions his or her own biases and assumptions about a patient’s background, abilities, or resources
• Asks the patient what has or has not worked for them before, and why
• Asks the patient to explain any questions or concerns they may have about the treatment plan
• Takes the patient’s understanding of the causes and potential cures of his or her condition into account when devising a treatment plan
• Works with the patient to come to an agreement about a treatment plan that the patient agrees with and can realistically maintain
• Provides a nutrition plan that is in accordance with the dietary customs of the patient
• Asks the patient which family members should be informed of their health situation and who should have the right to make decisions
• Makes certain that patients with limited English proficiency (LEP) have full access to care and services in a language that they can understand
• Instead of asking, “Do you understand?”, asks the patient to repeat what they understood in their own words

What is linguistic competency?

Most healthcare providers encounter situations in which they and their patients do not share the same native language.  Even if a provider does not speak a patient’s preferred language, he or she can take steps to ensure successful patient-provider communication and reduce the risk of misunderstandings.

Why is linguistic competency important?

More than 67 million U.S. residents (age 5 or older) – or about 22% of the total population – speak a language other than English at home. About 26 million or 40% of these residents are considered limited English proficient (LEP), meaning they reported speaking English less than “very well” on the U.S. Census Bureau’s American Community Survey. Approximately 12% of Medicare beneficiaries report that English is not their primary language and 8% are considered to have limited English proficiency.

The language used in healthcare situations is complex and can be difficult to follow, even for someone who has a basic understanding of English.  It is common for an English language learner to manage most daily activities in English, but still be unfamiliar with medical terms.  The stress of dealing with medical conditions in a clinical setting can also make it more difficult to concentrate on functioning in a second language. 

Patients who are trying to navigate a complex healthcare system in a language that they do not fully understand are at greater risk for mistakes and complications due to miscommunication.  They have worse health outcomes, less access to preventive services, higher readmission rates and report less patient satisfaction.

When is a professional interpreter necessary?

The best practice is for all healthcare encounters with limited English proficient individuals be conducted through a professionally trained medical interpreter.  This minimizes the potential for mistakes and misunderstandings.  When no professional interpreter is available for the patient’s preferred language, telephone interpreting services provide a viable second option.  Wherever possible, written materials such as prescription labels, clinical summaries and discharge instructions should be professionally translated into the patient’s own language.

When translating medical information, small mistakes can have major consequences.  Untrained interpreters may omit important information, mistranslate key medical terms, or confuse matters by inserting helpful comments of their own into the translation.  For this reason, untrained interpreters such as friends and family members are the option of last resort, only to be used in emergency situations when no other interpreter can be found in time.

Do deaf and hard of hearing individuals need medical interpreters?

Deaf and hard of hearing patients face unique communication challenges.  Though individual communication needs and preferences vary, many deaf people use a sign language to communicate such as American Sign Language (ASL), Mexican Sign Language (MSL) or Chinese Sign Language (CSL).  These sign languages are complete and fully-developed languages with their own vocabulary, grammar, and syntax.  Professionally trained sign language interpreters should be provided for individuals who communicate using a sign language.

Some deaf and hard of hearing individuals can read lips if the speaker’s face is clearly visible. However, relying on lip-reading when discussing medical information is unreliable and can have serious consequences. When working with a deaf or hard of hearing patient, it is best to ask the person how they prefer to communicate. There are a range of communication services available for deaf and hard of hearing individuals.

What communication assistance might blind or low vision individuals need?

Similar to deaf and hard of hearing individuals, patients who are blind or low vision have unique needs and preferences. They may also have limited English proficiency if their primary language is not English. In this case, the best practice is to conduct for all clinical encounters through a professionally trained medical interpreter.  Written materials should be available in large print, braille, and audio or electronic file in the patient’s preferred language. Ask all blind and low vision patients in what format and language they would like written materials.

What does a linguistically competent provider do?

A linguistically competent provider:

• Realizes that patients who appear to have enough English language skills to manage most everyday situations often still have difficulty communicating fully in medical situations
• Uses a trained medical interpreter or telephone interpretation service (not a friend or family member, and especially not a child)
• Will not ask, “Do you understand?”, but will ask the patient to repeat what they understood in their own words
• Does not try to “get by” on a busy day with hand gestures or untrained ad-hoc interpreters
• Will only use a friend or family member to act as interpreter in an emergency situation and asks them to translate exactly what the patient says without adding extra comments and observations of their own
• Speaks directly to the patient, not to the interpreter
• Provides written materials both in English and in the patient’s preferred language whenever possible (some individuals can read English better than they can speak it, or vice versa)
• Makes sure that prescriptions are labeled in a manner that the patient can clearly understand
• Ensures that no patient is asked to sign a consent form that is written in a language or format that he or she does not understand
• Offers blind and low vision patients materials in large print, braille, and audio or electronic format

What is a language access plan?

According to the CMS Office of Minority Health, “A language access plan can help ensure that an organization provides high quality and appropriate language services. A language access plan can help ensure that an organization’s staff members are aware of what to do when an individual with limited English proficiency needs assistance.

Understanding and working to address communication and language needs of patients is a critical part of ensuring high quality care. A language access plan documents how to provide services to LEP patients or patients who do not speak English, as well as those who are deaf, hard of hearing, blind or low vision.

Why is it important to collect and document race, ethnicity, and language data (REaL)?

Information that a provider or organization collects about patients helps the healthcare team to communicate effectively based on the patients’ unique needs by understanding their culture and language preference. This information becomes part of the patient’s medical record and can be used to prepare for each clinical encounter. For example, if it is noted in the patient’s medical record that he or she is limited English proficient, a professional language interpreter can be ordered in advance of an appointment. It is important to establish a systematic process for collecting patients’ REaL data.

Why do we need a more diverse healthcare workforce?

As the number of minority people in the U.S. grows, so does the need for culturally and linguistically competent care.  The most effective way to fill this need is to build a more diverse healthcare workforce, and train healthcare professionals of all backgrounds to work and communicate more effectively with people whose backgrounds differ from their own.  The number of minority people in the healthcare professions is increasing, but not steadily enough to achieve true parity. More effort is needed to recruit young people from underrepresented populations into the healthcare professions and provide them with the resources and education they need in order to become doctors, nurses, and other healthcare professionals.

What resources are available to help improve cultural and linguistic competency?

The resources on the following pages include articles, websites, toolkits, and other resources that will be of interest to those providers and organizations dedicated to reducing health disparities in their own communities and improving the care they provide to their patients.