Contributors: Maribel Alcala MHSM, BSN, RN,
Angeles Nava, Ph.D., RN and
Francisco Javier Ayala DNP, MSN, APRN, FNP-C, CCRN

Introduction

According to the United States Census Bureau (2019), Spanish-language speakers represented 13.5% of the United States population, making Spanish the second most spoken language in the U.S. (Christy et al., 2021). Spanish speakers are projected to reach more than 43 million by 2020 (Soto Mas & Jacobson, 2019). The state of Florida leads with the highest percentage (45.9%) of the Hispanic population, followed by Texas (39.7%) and California (30.6%) (United States Census Bureau, 2021). According to Nava et al. (2022), it is essential for Hispanics/ Latinos whose primary language is Spanish to advance and to understand the best use of contemporary and culturally humble language.

For many Spanish speakers with limited English-speaking skills, health care encounters in the U.S. represent a challenge. Effective and accurate communication is essential in the healthcare arena for patient safety. Who are those Hispanic/ Latinos who speak Spanish? Latin America is comprised of 20 countries from North (Mexico), Central (Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica, and Panama), and South America (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Paraguay, Peru, Uruguay, and Venezuela) as well as the Caribbean (Cuba, Dominican Republic, and Puerto Rico) (Nava et al., 2022).

            This blog reviews the complexity of health inequities, cultural care, language, and ethical issues that affect the diversity of the Hispanic/ Latino population in the United States. Hispanic/ Latino population comprises 20 countries that speak Spanish as their primary language, and it is the second most spoken language in the U.S. The Hispanic population contributes to the economy, cultural diversity, and the nation’s health. Madeleine Leininger’s Culture Care Theory addresses how a particular culture’s values, beliefs, norms, and lifeways guide thinking, decision-making, and actions. Communication methods (verbal and written) in Spanish are needed to meet the needs of Spanish-speaking patients, including access to healthcare and equity. Nurses’ roles are essential to advocate for patients who need Spanish educational resources to ensure Hispanics/ Latinos receive healthcare in their language.

Who are those Hispanic/ Latinos who speak Spanish?

The vulnerability of the Spanish-speaking population in the United States who immigrated to this country looking for a better quality of life, leaving behind what they have been taught for generations, their homes, families, and, most importantly, their rich culture. The Hispanic population contributes to the economy, cultural diversity, and the nation’s health. Madeleine Leininger predicted that culture and care were embedded in each other and needed to be understood and provide culture-specific care that would be culturally congruent, safe, and beneficial to people of diverse cultures for their health and healing. Nurses are the first healthcare provider; these Spanish-speaking patients or families spend more time with the nurse, and nurses advocate for all patients. It is imperative for the nurses in the Nation to understand and learn to respect and include Spanish culture and language diversity.

Language Barriers and Healthcare Access

 Language affects how we communicate, understand, and respond to health information. Language skills and proficiency also play a crucial role in patients’ self-efficacy and are essential to developing health literacy (Soto Mas & Jacobson, 2019). Language barriers between nurses and patients increasingly affect nursing practice, regardless of where care is delivered. Research has shown the impact of language barriers on healthcare delivery and patient outcomes. Public health, access to healthcare, and equity considerations exist for the need for the Spanish language, including in advertising in the pharmaceutical industry. Communication methods (verbal, written, and advertisement) in Spanish are needed to meet the needs of Spanish-speaking patients, including access to healthcare and equity. The Nations Healthcare communication should engage in the practice, including but not limited to all ethnicities, public and private healthcare settings to improve health resources in Spanish, including pharmacies and/ or pharmaceutical education. In addition to a safety risk, language barriers are also an ethical issue. Hispanics/ Latinos have experienced higher mortality and morbidity due to lower access to care and a lack of accurate information or disinformation (Enriquez et al., 2021). Language access is undoubtedly the key to communication (Showstack et al., 2018).

Ethical Dilemma to Healthcare Quality

Almost 6 out of 10 Hispanics reported having difficulty communicating with healthcare providers due to language barriers (bfw Life Science, 2022). Moreover, research has shown that most Hispanic immigrants are at a higher risk of having limited health literacy because they must confront the many barriers of a healthcare system offered predominately English-language healthcare system (Soto Mas & Jacobson, 2019; Showstack et al., 2018). The COVID‐19 pandemic highlighted the stark racial and ethnic inequities experienced by people belonging to historically marginalized groups (Nava et al., 2022). According to CDC COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), on May 14, 2020, hospitalization and death rates were significantly elevated in the Hispanic population compared to Whites—with a 2-fold higher age-adjusted death rate for the Hispanic population (204.6 per 100 000 vs 90.4 per 100 000) (Macias Gil et al., 2020).

Latino caregivers who experience limited English Proficiency (LEP) face communication barriers to quality health care (Riera et al., 2017a). Latinos who reported experiencing worse health outcomes were monolinguals (Spanish only) compared to bilinguals (Spanish/ English) contributed to poor health outcomes. Latinos suffer from poorer health and are less likely to receive high-quality care research by Cabral and Cuevas (2020) shows that racial biases among healthcare providers may partly explain treatment differences, and these biases operate at the unconscious level. For instance, clinicians hold negative stereotypes of racial/ethnic groups, and these biases may manifest in nonverbal behaviors and influence decision-making.

 Some Latinos find their health care in non-clinical places, relying on folk medicine and traditional healers. This reliance does not necessarily replace modern biomedicine; Western medical care often utilizes herbal remedies and other non-allopathic treatments. In addition to cultural factors, limited or lacking health literacy may play a vital role in the low use of Western treatments. For example, one of the top diseases in the U.S. is that one in two Hispanic/ Latinos will develop diabetes over their lifetime, and 66% are at greater risk of developing type 2 diabetes once diagnosed (Shiro & Reeves, 2020).

Culture Care Theory

Madeleine Leininger’s theory of Transcultural Nursing, also known as Culture Care Theory, identifies nursing decisions and actions that achieve culturally friendly care for the patient, specifically for nurses who are not Spanish-speaking. Leininger defined culture as the learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular culture that guide thinking, decisions, and actions in patterned ways (McFarland & Wehbe-Alamah, 2019). It is fundamental to improve the nurse’s knowledge and strengthen based approaches to the nurse-patient relationships by emphasizing the sensitivity of the culture of the whole person rather than viewing the patient as a set of symptoms or an illness. There are many reasons for nurses to use the cultural understanding of patients’ cultural backgrounds in their assessments. It facilitates nurses to know how the patient’s culture and faith support their experiences when dealing with illness, suffering from pain, and death.

Our Role as Professional Nurses

How can nurses help improve care quality and ethical outcomes for patients with limited English proficiency for this vulnerable Spanish-speaking population? The Hispanic/ Latino population is diverse, and one size fits all does not apply to this population. Proper identification among Hispanic/ Latino people remains a fundamental challenge for clinical nurses and nurse scientists working with this diverse population, but successful practices will help advance health equity (Nava et al., 2022). For nurses to organize their care better, evidence-based strategies are needed to improve outcomes and meet The Joint Commission requirements for bridging language barriers (Squires, 2018). Nurses can advocate for patients who need Spanish educational discharge resources to ensure Hispanics/ Latinos receive services in their language. We can improve the nursing practice from the perspective of Leininger’s Theory. Improving Latino health will require concerted policy intervention (Shiro & Reeves, 2020). Improving the health of Latinos demands bold policies that address the language barrier that influences access to health care. Bilingual nurses (English/ Spanish) need to be involved in policy changes in health care settings to help bilingual nurses become certified interpreters/ translators with increased compensation. Create and participate in communities to develop and review written materials in Spanish for patients.

References

bfw Life Science. (2022). Why pharma advertising in multiple languages is rare- and why it shouldn’t be. https://healthcareadvertising.gobfw.com/pharma-advertising-in-multiple-languages/

Cabral, J., & Cuevas, A. G. (2020). Health inequities among latinos/hispanics: Documentation status as a determinant of health. Journal of Racial and Ethnic Health Disparities, 7(5), 874–879. https://doi.org/10.1007/s40615-020-00710-0

Christy, S. M., Cousin, L. A., Sutton, S. K., Chavarria, E. A., Abdulla, R., Gutierrez, L., Sanchez, J., Lopez, D., Gwede, C. K., & Meade, C. D. (2021). Characterizing health literacy among spanish language-preferring latinos ages 50–75. Nursing Research, 70(5), 344–353. https://doi.org/10.1097/nnr.0000000000000519

Enriquez, M. (2021). Journal description. Hispanic Health Care International. https://www.journals.sagepub.com

Enriquez, M., Remy, L., & Dickson, E. (2021). Two years in: The covid-19 pandemic and hispanic health. Hispanic Health Care International, 19(4), 210–211. https://doi.org/10.1177/15404153211045658

Ma, M. A., Gutiérrez, D. E., Frausto, J. M., & Al-Delaimy, W. K. (2021). Minority representation in clinical trials in the United States. Mayo Clinic Proceedings, 96(1), 264–266. https://doi.org/10.1016/j.mayocp.2020.10.027

Macias Gil, R., Marcelin, J. R., Zuniga-Blanco, B., Marquez, C., Mathew, T., & Piggott, D. A. (2020). Covid-19 pandemic: Disparate health impact on the hispanic/latinx population in the united states. The Journal of Infectious Diseases, 222(10), 1592–1595. https://doi.org/10.1093/infdis/jiaa474

McFarland, M. R., & Wehbe-Alamah, H. B. (2019). Leininger’s theory of culture care diversity and universality: An overview with a historical retrospective and a view toward the future. Journal of Transcultural Nursing, 30(6), 540–557. https://doi.org/10.1177/1043659619867134

Nava, A., Estrada, L., Gerchow, L., Scott, J., Thompson, R., & Squires, A. (2022). Grouping people by language exacerbates health inequities—the case of latinx/hispanic populations in the us. Research in Nursing & Health, 45(2), 142–147. https://doi.org/10.1002/nur.22221

Riera, A., Ocasio, A., Tiyyagura, G., Thomas, A., Goncalves, P., Krumeich, L., Ragins, K., Trevino, S., & Vaca, F. E. (2017). A web-based educational video to improve asthma knowledge for limited english proficiency latino caregivers. Journal of Asthma, 54(6), 624–631. https://doi.org/10.1080/02770903.2016.1251597

Shiro, A. G., & Reeves, R. V. (2020). Latinos often lack access to healthcare and have poor health outcomes. Here’s how we can change that. Brookings. https://www.brookings.edu/blog/how-we-rise/2020/09/25/latinos-often-lack-access-to-healthcare-and-have-poor-health-outcomes-heres-how-we-can-change-that/

Showstack, R. E., Guzman, K., Chesser, A. K., & Woods, N. (2018). Improving latino health equity through spanish language interpreter advocacy in kansas. Hispanic Health Care International, 17(1), 18–22. https://doi.org/10.1177/1540415318818706

Soto Mas, F., & Jacobson, H. E. (2019). Advancing health literacy among hispanic immigrants: The intersection between education and health. Health Promotion Practice, 20(2), 251–257. https://doi.org/10.1177/1524839918761865

Squires, A. (2018). Strategies for overcoming language barriers in healthcare. Nursing Management, 49(4), 20–27. https://doi.org/10.1097/01.numa.0000531166.24481.15

United States Census Bureau. (2021). Quick facts statistics. https://www.census.gov

About the Contributors

Maribel Alcala is a bilingual Patient Education Liaison for Alnylam, a biopharmaceutical company in the RNAi scientific space. Mari is a healthcare professional with outstanding clinical leadership in the hospital setting and expertise in nursing clinical research for best practices, integration, education, system redesign, and quality improvement in Spanish-speaking patient-focused. Mari’s passion for solid scientific and strong interest in emerging treatment modalities and helping Spanish-speaking patients/ families with innovative best practices utilizing the nursing philosophy of Leininger’s Culture Care.

Angeles Nava, Ph.D., is an Assistant Professor at Texas Woman’s University, College of Nursing. Her research interest is intimate partner violence, focusing on Hispanic/Latina immigrant women. Dr. Nava has participated in quantitative and qualitative research on intimate partner violence, economic solvency, and long-term support groups for abused women.

Francisco Ayala, DNP, is an Assistant Clinical Professor at Texas Woman’s University. Dr. Ayala’s research interests include disparities in minority groups and health inequalities in patients with low SES. Academic interests include DNP curriculum design and DNP scholarly project implementation. Dr. Ayala is a practicing Family Nurse Practitioner volunteer NP providing primary care to uninsured and low-income individuals. Dr. Ayala teaches in the undergraduate and graduate Schools of Nursing and is based out of the Houston Campus.