Every day in hospitals and clinics throughout the U.S., patients whose preferred language is not English face significant barriers to receiving high-quality care. They often find it challenging to obtain language services. As primary providers of direct patient care, nurses play a key role in identifying the need for language assistance and ensuring patients receive proper support.

In the U.S., there are over 25 million people with limited English proficiency (LEP), meaning they face persistent obstacles in navigating a system that largely operates in English. These barriers disproportionately affect marginalized groups, who often rely on the emergency department (ED) for care. For these individuals, language barriers can contribute to more avoidable ED revisits, hospital readmissions, and prolonged hospital stays.

A growing body of research, including a recent study in Nursing Outlook by LDI Senior Fellows K. Jane Muir and Karen Lasater, and colleague Kathy Sliwinski, underscores how hospital investments in nursing resources may help reduce disparities in this understudied group.

The study—one of the first to examine ED outcomes for people with LEP—found they were more likely to experience avoidable ED revisits than those without LEP, but that disparity was less pronounced in hospitals with favorable nurse work environments.

In the study, individuals with LEP had 12% higher odds of revisiting an ED within 72 hours than individuals with English proficiency. These revisits—commonly called “bounce-back visits”—are considered avoidable encounters that may indicate unmet care needs during the initial ED visit. In hospitals where nurses had more professional autonomy and involvement in unit decision-making (e.g., protocols for starting interpreter services), adequate staffing, strong cross-department collaboration and unit management, and a culture of high-quality patient care, people with LEP were less likely to experience ED revisits. Specifically, the probability of an ED revisit for people with LEP fell by 1.3 percentage points when treated in favorable versus unfavorable nurse work environments.

The observational study was large, with 1.3 million patients in 64 EDs across New Jersey, where 40% of residents speak a language other than English. While the study did not directly evaluate for causal relationships between nursing resources and outcomes, it strongly suggests that nurse work environments are influential on outcomes for this group.

While language services like interpreters are legally required for individuals who need them under Section 1557 of the Affordable Care Act, they are inconsistently used for many reasons including clinician time constraints, equipment failures, and bias. Advancements such as virtual platforms, telephonic, and/or video conferencing interpretation have been integrated into large systems, including Penn Medicine. Leaders should consider whether clinicians have enough time and resources in their work environment to give these services.

Increasingly, executives, including LDI Senior Fellow and Penn Medicine CEO Kevin Mahoney, have actively supported better nurse work environments by investing in more nurses at the bedside. This advocacy is supported by over two decades of evidence showing that when nurses have high caseloads, patients are 7% more likely to die and have higher odds of avoidable readmissions.

Additional evidence shows that hospitals can reduce these outcomes and save money by investing in safer nurse staffing levels. In recent years, momentum has increased to support safe staffing ratios in multiple states, including Pennsylvania through the Patient Safety Act, which mandates patient-to-nurse staffing ratios across health care units. This legislation is currently stalled in the Pennsylvania Senate; individuals can call their local representatives to express their views on this.

Addressing disparities for individuals with LEP requires systemic change. Here are key policy solutions for administrators, state legislators, and federal policymakers:

1. Reinforce Policies for Language Access Services: These are required by Title VI of the Civil Rights Act of 1964, and re-enforcing these standards in hospitals is essential to deliver high-quality and equitable care. Such policies also show the importance of qualified professionals providing interpreter services to people with LEP rather than clinicians/staff without formal training.
2. Provide High-Quality Language Resources: Institutions must ensure that clinicians have in-person interpreter services and high-quality equipment (e.g., tablets or phones) to do their work.
3. Ensure Safe Nurse Workloads: Nurses cite time constraints as a key barrier to providing high-quality care to individuals with LEP. Adequate staffing can help ease this constraint.
4. Improve Workforce Diversity: Advancing a more diverse workforce from the perspective of multilingualism, race/ethnicity, and experiences of those from disadvantaged backgrounds can make care more equitable. Helping multilingual clinicians become certified medical interpreters may also foster better encounters.
5. Expand Cultural Competency Programs and Requirements: Establish ongoing training programs in systems across different modalities (e.g. in-person and virtual), reflecting the experiences and demographics of patients served. Penn’s Multilingual Approaches to Research Studies (MARS), led by faculty at Children’s Hospital of Philadelphia (CHOP) and community leaders, provides interactive training for individuals working with LEP populations.
6. Advancing Language Access Standards. Hospital designations such as the Magnet Recognition Program for nursing excellence can be updated to integrate the inclusion of accessible language access services as a key element of high-quality patient care and supportive nurse work environments.

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The study, “Reducing Disparities in Emergency Department Outcomes for Individuals with Limited English Proficiency: The Nurse Work Environment,” was published on November 28, 2024 in Nursing Outlook. Authors include Kathryn Jane Muir, Kathy Sliwinsk, and Karen B. Lasater.

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Additional Resources:

Sliwinski, K., & Squires, A. P. (2024). Limited English Proficiency Is an Overlooked Research Demographic. AJN The American Journal of Nursing, 124(6), 8.

Sliwinski, K., Kutney-Lee, A., McHugh, M. D., & Lasater, K. B. (2024). A Review of Disparities in Outcomes of Hospitalized Patients with Limited English Proficiency: The Importance of Nursing Resources. Journal of Health Care for the Poor and Underserved, 35(1), 359-374. 

Sliwinski, K., Ancheta, A. J., Muir, K. J., & Lasater, K. B. (2024). Mapping Segregation Patterns of Hospital Care among Patients with Limited English Proficiency. Journal of Immigrant and Minority Health, 1-4. 

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