The SHARE Approach

Overcoming Communication Barriers

With Your Patients: A Reference Guide
for Health Care Providers
Workshop Curriculum: Tool 3

The SHARE Approach is a 1-day training program developed by the Agency for Healthcare Research
and Quality (AHRQ) to help health care professionals work with patients to make the best possible
health care decisions. It supports shared decisionmaking through the use of patient-centered outcomes
research (PCOR).
 Communication barriers get in the way of
good health care
This guide offers tips for overcoming communication challenges
so you and your patients (and the families and friends who
accompany them) can engage in effective shared decisionmaking.
This guide also focuses on ways to efficiently work with qualified Did you know it’s the law?
medical interpreters. Civil Rights Act. All health
care providers who get Federal
Language, hearing, and visual barriers are funds must ensure equal access
common in the United States to services. Offering a qualified
medical interpreter, free of
charge, and having translated
Consider these statistics: written materials is a good way to
overcome language barriers with
› Approximately 9 out of 100 people have limited
patients (and companions) with
English proficiency.
limited English proficiency.
› More than 3 out of 100 people have a hearing disability. That means
If a patient chooses to use a family
they are deaf or have severe trouble hearing.
member or friend as an interpreter,
› More than 2 out of 100 people have a visual disability. That means it’s a good idea to use your own
they are blind, or have severe trouble seeing, even with glasses. interpreter as well.
Americans with Disabilities
Act. All health care providers
(regardless of funding) must
provide effective communication,
free of charge, to patients (and
companions) with disabilities.
The method of providing effective
communication can vary. It may
include using a qualified medical
interpreter, providing large-print
materials, or writing
out instructions.
Informed consent. Based
on statute, regulation, and
case law, the informed consent
process requires explanations
of the benefits and risks of
treatment alternatives.

Overcoming Communication Barriers With Your Patients: A Reference 2

Guide for Health Care Providers (Workshop Curriculum: Tool 3)
 Set the stage for good communication
Shared decisionmaking helps patients take charge of their care. In order to give fully informed
consent, patients need information they can understand. Their companions (family members or
friends who accompany them) do, too.

Check off the strategies you will try.

Assess and record your patients’ communication needs. Choose decision aids that match the
needs of your patients.

Find or train qualified medical interpreters.

Tell patients (and companions)—verbally and in writing—that you provide interpreters and
decision aids that enhance communication.

Train staff to better serve patients who have communication barriers.

Choose decision aids that enhance communication

There are many decision aids that can transcend barriers to communication. Here are just a few.

Language barriers

› Materials that are culturally appropriate, translated, or written in plain language

› Visuals like pictures and graphs

Hearing barriers

› Print materials
› Text telephones (TTYs)
› Videos with captions
› Written instructions

Visual barriers

› Audio recordings
› Large-print materials and screen magnifiers
› Screen reader software (a software
application that is a form of assistive
technology, which can re-present information in
text-to-speech, sound icons, or a Braille output device)

Overcoming Communication Barriers With Your Patients: A Reference 3

Guide for Health Care Providers (Workshop Curriculum: Tool 3)
 Qualified medical interpreters can help with language or
hearing barriers.
Qualified medical interpreters can be certified freelance interpreters; employees from language
agencies; trained bilingual clinicians and staff; or community-based medical interpreters from
local colleges, faith-based organizations, social services programs, migrant health clinics,
and more.

The use of unqualified interpreters—such as a family member, minor child, friend, or unqualified
staff member—is not advisable. That choice is more likely to result in misunderstandings and
medical errors.

Language barriers

A qualified medical interpreter who helps people with limited English proficiency is trained in:
› Ethical standards
› Cultural issues
› Health care words and concepts
› How to interpret between languages
› How to translate instructions
› Relevant languages for your patients
› Correct positioning in the room

Hearing barriers

There are several types of qualified medical interpreters that help

people who are deaf or hard of hearing.
› Sign language interpreter. This person uses American Sign
Language or Signed English.
› Oral interpreter. This person articulates silently and clearly,
and uses gestures.
› Cued-speech interpreter. This person does everything an oral
interpreter does, but also uses a hand code to stand for each
speech sound.

Overcoming Communication Barriers With Your Patients: A Reference 4

Guide for Health Care Providers (Workshop Curriculum: Tool 3)
 Checklist for working with qualified medical interpreters onsite

Before the visit

Gather any needed decision aids. Make sure they match the communication needs of your
patient (and their companions).

Tell the interpreter what the visit will be about. Make sure the interpreter understands the
information, especially if the patient’s life may be at risk.

During the visit, make sure

Everyone in the room can see each other.

Your patient knows the interpreter’s name and what the interpreter will do.

Your patient knows that the interpreter is a confidential source who will not share any of
the information.

Your patient is making the health care decisions. Some patients defer to their interpreter to
make choices for them.

Your patient understands the main points. Use teach-back to make sure you presented
information in a way your patient understands. Have your patient explain to you, in his or
her own words, what you said. Ask the interpreter to tell you exactly what your patient said
so you can check for comprehension.

Working with offsite qualified medical

interpreters
When working with offsite interpreters, make sure you and your
staff know how to use any needed equipment, such as dual
handsets or speaker phones in the exam rooms.

Over-the-phone interpreters

Trained telephonic interpreters provide offsite multilingual

interpretation to the patient and health care provider by
telephone. This service is also called a language line.

Videoconferencing

The interpreter can see, hear, and assess the body language of the
patient and the health care provider via a video remote interpreting service.

Overcoming Communication Barriers With Your Patients: A Reference 5

Guide for Health Care Providers (Workshop Curriculum: Tool 3)
 Avoid working with untrained (or unqualified) medical interpreters
Using unqualified medical interpreters should be avoided to protect patients and providers. Still,
at times, your patient may want their bilingual family member to interpret for them—and, of
course, you want to honor their request.

Letting your patients use an interpreter of their choice does not, however, mean a qualified
medical interpreter cannot be present to make sure no mistakes are made. Using untrained staff to
interpret has been shown to lead to clinically significant medical errors.

There are challenges with using unqualified interpreters

› They may be unfamiliar with technical or scientific language.

› They may inadvertently commit interpretive errors.
› They may editorialize your patient’s responses.
› When a family member interprets, the person may impose their view of your patient’s health
and this may also pose a problem with patient privacy.
› When a minor child interprets, the child is in a very vulnerable position and the practice is at
risk for liability if something goes wrong. Also, your patient may be less likely to discuss more
personal health topics when a minor child interprets.

If you must work with an untrained interpreter, make

sure information is being exchanged accurately

Try these tips

› Never use minor children to interpret.

› Remind the interpreter to interpret everything accurately
and completely.
› Ask the interpreter to avoid paraphrasing or answering for
your patient.
› Interact frequently with your patient and use teach-back.

Funding qualified medical interpreters

Here are some ways to pay for qualified medical interpreters:

› Find out if your State’s Medicaid or State Child Health Insurance Plan reimburses for
interpreters or contracts with interpreter organizations.
› Develop collaborative contracts with other practices and hospitals in your region for onsite
interpreters or an offsite telephone interpreter service.
› Arrange for your bilingual staff to get trained and become qualified medical interpreters.

Overcoming Communication Barriers With Your Patients: A Reference 6

Guide for Health Care Providers (Workshop Curriculum: Tool 3)
 Learn more about resources for health care providers

For information about working with qualified medical interpreters and cultural
competency, visit:

› A Patient-Centered Guide to Implementing Language Access Services in

Healthcare Organizations
http://minorityhealth.hhs.gov/templates/content.aspx?ID=4375&lvl=3&lvlID=52
› Health Literacy Universal Precautions Toolkit, Tool 9, pages 41-45, How to Address
Language Differences, AHRQ Pub. No. 10-0046-EF
http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/
literacy-toolkit/healthliteracytoolkit.pdf

Learn more about resources for patients

For culturally appropriate interactive decision aids from the Agency for Healthcare
Research and Quality, visit:

› http://www.effectivehealthcare.ahrq.gov/index.cfm/tools-and-resources/patient-
decision-aids/

For consumer research summaries that compare treatment options for a

variety of health conditions (most in both English and
Spanish), visit:

› http://www.effectivehealthcare.ahrq.gov/index.cfm/research-
summaries-for-consumers-clinicians-and-policymakers/

A limited number of copies are available at no cost through

the AHRQ Clearinghouse. All AHRQ resources are freely
available online.

This tool is to be used in conjunction with the Agency for Healthcare Research and Quality’s SHARE
Approach workshop. To learn more about the workshop, visit www.ahrq.gov/shareddecisionmaking.

Overcoming Communication Barriers With Your Patients: A Reference 7

Guide for Health Care Providers (Workshop Curriculum: Tool 3)
 Bibliography
A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations. Prepared by American
Institutes for Research, under Contract No. 282–98–0029, Task Order No. 48 Office of Minority Health. 2005.

Disability Status Report United States. Employment and Disability Institute at the Cornell University ILR School. 2011.

Flores G. Language barriers to health care in the United States. N Engl J Med 2006 Jul 20;355(3):229-31.
PMID: 16855260.

Betancourt J., Renfrew M., Green A., et al. Improving Patient Safety Systems for Patients With Limited English
Proficiency: A Guide for Hospitals. Prepared by The Disparities Solutions Center, Mongan Institute for Health
Policy, under Contract No. HHSA290200600011I. AHRQ Publication No. 12-0041. Rockville, MD: Agency for
Healthcare Research and Quality; November 2012.

Schapira L., Vargas E., Hidalgo R., et al. Lost in translation: Integrating medical interpreters into the multidisciplinary
team. The Oncologist 2008 May;13(5):586-92. PMID: 1851574.

Overcoming Communication Barriers With Your Patients: A Reference www.ahrq.gov/shareddecisionmaking

Guide for Health Care Providers (Workshop Curriculum: Tool 3) April 2014 | AHRQ Pub. No. 14-0034-3-EF