In this brief article, we describe an innovative graduate-level course in Spanish for counseling for chronic disease management that incorporates cultural knowledge of type 2 diabetes management, motivational interviewing skills, and strategic communication in Spanish.
Language barriers affect millions of health care consumers each year in the United States (Meuter et al., 2015). One in five U.S. residents over the age of 5 years speaks a language other than English at home, with Spanish being the most commonly spoken second language (U.S. Census Bureau, 2010). Providing quality health care to Spanish speakers presents a challenge because it requires the provision of health care interpreters, bilingual community health workers and navigators, and, optimally, language concordant health care providers including physicians, nurses, and other health professionals (Jacobs & Diamond, 2017). Further, language concordant providers should be able to engage in both health communication and health coaching with Spanish-speaking patients (Lor & Martínez, 2020).
The teaching of medical Spanish has gained increasing attention (Ortega et al., 2019). Although nurses play a critical role in providing care to Spanish-speaking patients, most programs in medical Spanish are geared toward medical students or undergraduate students in the life sciences and premedicine. Programs addressing nurses account for less than one third of all documented medical Spanish programs (Long & Uscinski, 2012; Hardin, 2015; Hardin & Hardin, 2013). This underrepresentation of medical Spanish programs for nurses is a pressing problem given that nurses provide the bulk of frontline care to Spanish-speaking populations (Squires, 2017).
Spanish for Nursing
Notwithstanding the underrepresentation of Spanish for nursing in the wider field of Spanish for the health professions, nurse educators and language educators have led the way in the development of Spanish for nursing curricula at the undergraduate and graduate levels. Undergraduate Spanish for nursing courses increase confidence in basic conversational Spanish, to conduct a basic interview in Spanish, to articulate and respond to patient concerns, and to understand cultural and social factors that influence nurse–patient communication with Spanish speakers (Baldwin, 2015; Krowchuk & Moore, 2004; Wright et al., 2010), and they successfully develop effective use of a variety of communication strategies in Spanish that contribute to successful use of the language in communicating with and caring for the Latinx patient (Bloom et al., 2006). Graduate-level courses, on the other hand, bridge previous knowledge of the language with the medical terminology and cultural understanding needed to effectively serve monolingual, Spanish-speaking patients and result in participants being more likely to continue developing their language skills after the course and to actively seek out both personal and professional language learning opportunities (Arraiza et al., 2005; de Pheils & Saul, 2009; Kelley & Klopf, 2008). However, there is a gap in the development of the specific linguistic and cultural skills needed to respond to the most pressing challenges Spanish speakers face in health care. Chronic illnesses such as type 2 diabetes mellitus (DM2) constitute a significant health challenge facing Spanish speakers today. The Centers for Disease Control and Prevention (CDC) notes that Hispanics adults are 1.7 times more likely than non-Hispanic adults to have a DM2 diagnosis (CDC, 2019), 2.6 times more likely to develop end-stage renal disease related to DM2 (Agency for Healthcare Research and Quality, 2019), and 1.4 times more likely to die from DM2 (CDC, 2019). Addressing these challenges requires moving beyond basic communication and developing relationship-building conversational skills. Health and wellness coaching is one approach that incorporates these more advanced skills.
Wolever et al. (2013) used a comprehensive, systematic review of health care literature to define health and wellness coaching. The conceptual and interventional components of health and wellness coaching include a patient-centered approach wherein patients at least partially determine their goals, use self-discovery or active learning processes together with content education to work toward their goals, and self-monitor behaviors to increase accountability. The coach is a health care professional trained in behavior change theory, motivational strategies, and communication techniques. These abilities then are used to assist patients to develop intrinsic motivation and obtain skills to create sustainable change for improved health and well-being. Health and wellness coaches do not simply provide information to patients, but rather they help patients to determine the type and amount of information they need when they are ready to hear it (Sforzo et al., 2017; Wolever et al., 2013). Therefore, health and wellness coaching acknowledges the individual, is collaborative, and encourages active learning. In the College of Nursing at The Ohio State University and The University of Arizona, health and wellness coaching has emerged as a critical competency in nursing education; thus, the development of Spanish for Nursing with a focus on health and wellness coaching skills was a natural fit for their students.
We describe the didactic content and learning activities developed in connection with a novel graduate-level Spanish for Nursing curriculum offered at each university that combines cultural knowledge of DM2 and motivational interviewing (MI) skills with strategic communication skills in the Spanish language.
Chronic Care Counseling for the Latinx Patient
The course was open to graduate-level nurse practitioner students and upper division nursing students who were motivated to use Spanish in clinical practice and who demonstrated a minimum proficiency level of novice high or intermediate low on the American Council on the Teaching of Foreign Languages (2012) proficiency scale. Enrolled students could use health coaching time as clinical hours toward specialty certification in their area under faculty supervision. The course was designed by a multidisciplinary team consisting of applied linguists and nurse educators, as well as an instructional design specialist to address online delivery. The course was team taught by faculty from the College of Nursing and the Department of Spanish and Portuguese. The expected learning outcomes for the course included (a) applying fundamental elements of clinical conversations, (b) using patient-centered communication (PCC) and demonstrating understanding of its role in culturally sensitive health care, (c) applying knowledge of Latinx health practices and cultural beliefs relevant to chronic care, (d) explaining cultural beliefs and social structures that affect the health status of Latinx populations in the United States, (e) engaging in clinical conversations in Spanish, and (f) proficiently conducting a motivational interview in Spanish.
The course was organized around three core content components: management of DM2, MI competencies, and strategic communication in Spanish.
The DM2 management component of the course introduced students to DM2 pathophysiology and to the epidemiology of DM2 in Spanish-speaking communities. Course faculty provided students with basic concepts of honoring Latinx cultural values such as familism, collectivism, and spirituality. Faculty provided students with guidance related to nutritional counseling emphasizing culturally appropriate ways of discussing food and dietary changes, techniques for promoting physical activity, and pharmacological interventions in DM2. Students learned the challenges that many Spanish-speakers face related to “social determinants of health.” These included being uninsured or underinsured, living in food deserts, and living in neighborhoods without parks and community centers to provide opportunities for physical activity. Among comorbidities associated with DM2, depression was identified as a potential barrier to behavior change. Cultural considerations and taboos associated with mental health were also discussed.
The MI component of the course introduced students to the major processes of MI and helped the students develop the core skills summarized in the OARS (Open questions, Affirmation, Reflective listening, and Summarizing) acronym (Miller & Rollnick, 2012). The MI content included a presentation of behavior change theory, the relationship of core MI skills to behavior change, and identification of change talk in Spanish (Prochaska et al., 2007). The importance of the patient making the choices about the behaviors they wished to change was stressed.
The Spanish language component of the course covered specific strategies for establishing rapport, showing interest, and talking about DM2 in Spanish. Strategies for establishing rapport included appropriate forms of address (tú/usted) and honorifics (don/doña). Strategies for showing interest included tactics of intersubjectivity such as establishing social sameness, affirming the inherent truth value of a patient's statements, and neutralizing power differentials in conversation (Bucholtz & Hall, 2005) are demonstrated in the following examples:
- Establishing social sameness: Patient: Tengo dos nietos, 2 y 5 años [I have two grandchildren, 2 and 5 years old]. Nurse: ¡Que edad tan divertida! [What a fun age!]
- Affirming truth value: Patient: Trabajo 8 horas al día, 6 días a la semana [I work 8 hours a day, 6 days a week]. Nurse: Le ha de ser muy difícil [That must be very difficult for you].
- Neutralizing power differences: Nurse: Usted es el experto aquí [You are the expert here].
Finally, strategies for talking about DM2 included common words and phrases related to DM2 such as the colloquial word for diabetes, el azúcar (sugar), technical terms for supplies such as glucómetro (glucometer), tiritas (strips), metformina (metformin), and appropriate metaphors for discussing DM2 pathology. For example, to talk about the function of glucose, clinicians may say, “el azúcar es como gasolina para el cuerpo” or “glucose is like gasoline for the body,” and to talk about insulin they may say, “la insulina es como una llave que deja que el azúcar entre a las células” or “insulin is like a key that allows glucose to enter the cells.”
Integrative activities were introduced throughout the course to consolidate knowledge and skills. Activities included discourse analysis, simulated mini-conversations, and standardized patient (SP) simulations.
Discourse analysis activities gave students the opportunity to discover the use of MI techniques in scripted conversations. Students analyzed Spanish scripts and identified key MI techniques. They were given the opportunity to reflect on and ask questions about grammatical and lexical form used in Spanish.
Simulated mini-conversations consisted of brief prompts presented to the student through a digital voice board. Students responded to five prompts ranging from relatively simple to more complex queries over the course of the semester. The following are examples of early and later digital voice board queries:
Activity 2.2: Doctora, mi hermano tiene diabetes y maneja números de 180 por la mañana y su doctor le dijo que estaba bien. ¿Por qué usted me dice que mi azúcar debe estar en 130 por la mañana? [Doctor, my brother has diabetes and his morning blood sugars are 180. His doctor said it was ok. Why are you telling me that my morning blood sugar should be 130?]
Activity 6.2: Pos fíjate que mi abuela tuvo diabetes y murió muy joven, muy joven, y yo quisiera saber si yo voy a morir de diabetes. [You know, my grandmother had diabetes and she died at a very young age. I'd like to know if I'm also going to die from diabetes.]
Students recorded a 1- to 2-minute response to the query and were assessed based on both clinical (addressing patient concerns and integrating course content) and linguistic (understandability and appropriate grammar and word choice) dimensions. In addition to the rubric evaluation, the students received verbal feedback from both the clinical and the language instructors on the digital voice board system.
Finally, students participated in three SP simulations (Table A; available in the online version of this article). The three simulations were structured as follows:
- In simulation 1, students were provided laboratory results for the SP and the students were asked to build rapport with the patient, obtain a history, and assess significant challenges faced in DM2 self-management using MI techniques.
- In simulation 2, the SP was instructed to identify a specific problem area in DM2 self-management. Students were asked to help the SP work through the problem area using MI techniques.
- In simulation 3, students were asked to query patients about specific problem areas and work on developing further goals using MI techniques.
Standardized Patient Script
All simulations were recorded and assessed by the instructors and the SP along clinical and linguistic dimensions. After students received their scores, a debriefing session was held with the students and both instructors. Students were invited to reflect on their performance, identify strengths and weaknesses, and list areas for improvement.
In developing and implementing this course, the authors learned a variety of important lessons about developing communication and coaching skills in Spanish for nurses. First, we learned that students who are motivated to learn Spanish had an intrinsic desire to gain in-depth cultural understanding related to health practices and beliefs. Our students commented positively on the relevance of the course material and on the value of learning about the reality of living with diabetes for Spanish-speaking patients. Second, we learned that opportunities for reflection on language performance were key to successful acquisition. Opportunities to reflect and debrief consistently led students to perform at a higher level on subsequent activities. Finally, we learned that a multidisciplinary team-teaching approach was ideal in developing culturally sensitive clinical language skills. This approach provided students with multiple perspectives for improving performance. For example, we provided recorded feedback on simulated mini-conversations from the perspectives of both faculty members and group feedback on SP simulations where both clinical and language faculty commented on student performance leading to an integrated and dialogic assessment.
Spanish for Nursing has gained increasing attention over the past 15 years. Although programs and courses have been developed at both the undergraduate and the graduate levels, a specific focus on counseling for chronic disease management has not yet been developed. In this brief article, we describe an innovative graduate-level course in Spanish for chronic disease communication and coaching that incorporates cultural knowledge of DM2 management, motivational interviewing skills, and strategic communication in Spanish. We concur with Krowchuk's and Moore's (2004) assertion “that it is now necessary for nursing education to include Spanish language and culture in their curricula” (p. 218). We agree and go a step further to assert that Spanish language instruction should include integrated opportunities to develop advanced skills that will be critical in providing care to Spanish-speaking patients with chronic illnesses.
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Standardized Patient Script
|LENGTH OF ENCOUNTER: 20 minutes + 10 minutes Debrief/Feedback|
|NAME: Juan Miguel Díaz (JMD)|
|AGE: 59-year-old male|
|ATTIRE: Casual attire|
|AFFECT: Pleasant, very agreeable, chatty and prone to making small talk, and interested and very curious about your health coach.|
|OVERALL PORTRAYAL GOAL/PRESENTATION/CHIEF COMPLAINT:|
|You were diagnosed with type 2 diabetes 2 years ago at Clínica Amistad (a local free clinic for the uninsured). Your wife insisted on the check up because of your persistent blurry vision. You were diagnosed and prescribed metformin. You never filled the prescription and never went back for follow-up. You told your wife that you were found in perfect health. Recently, a coworker who is about your age died of a sudden heart attack. You were close to him and knew he was diabetic. You are shaken up by this and afraid for your health. You decided to tell your wife about your diagnosis 2 years ago. You shared you are tired all the time, have blurry vision, get up two to three times per night to urinate, and are thirsty all the time. Now that you have insurance, your wife makes you an appointment with her nurse practitioner. You are now on metformin. You were sent to a dietician and another nurse who is a diabetes educator. You also need to have an eye examination. The only thing you remember is that your hemoglobin A1C is 9 and that it takes a lot of work to bring it down to less than 7. Your head is filled with too much information.|
|TARGET BEHAVIORS TO CHANGE:|
| Increase physical activity|
| Healthier food choices|
| Self-monitoring (home glucose testing)|
| “I am not good at taking pills and sometimes forget to take them.”|
| Fatalism about diabetes as a death sentence|
|Student: “What brings you in today?”|
|JMD: “I was told I need to see a health coach.”|
|Ad lib: “I am worried sick. My friend looked like he was doing well and he died so suddenly. I know I have to make many changes, but I don't know where to begin. I love to eat, my wife is trying to get me to eat healthy but my mother is always making me antojitos. I work all the time, and on weekends I am just exhausted so I can't even think about exercising.”|
|History of present illness: See above|
|Past medical history: Adult illnesses: hypertension, DM2, dyslipidemia|
|Medications: metformin, lisinopril|
|Immunizations: Up to date|
|Tests: Was told he needs a colonoscopy. He says “no way.”|
Mexican, born and raised in Tucson, parents and grandparents are from Hermosillo in Sonora, Mexico.
Had no health insurance for many years, now covered under Obamacare.
You just started seeing a primary care provider; you and your wife see the same family nurse practitioner.
You are married, have been married for 35 years. Have four adult children ages 34, 32, 30, and 25. Your youngest is a daughter who lives at home with a 2-year-old grandson and a baby (granddaughter). Your 77-year-old mother also lives in your household.
You are a bookkeeper and work long hours in a desk job.
Once in a while, you take your grandson to the park, your favorite pastime is watching soccer matches with your compadre and your sons.
You are a former smoker (one pack per day for 10 years), but you quit smoking almost 20 years ago when you turned 40.
You drink beer on weekends when watching soccer. Never more than three or four beers, stating “If I get too loud or worked up in a soccer match my wife cuts me off.”
|Breakfast: Huevos rancheros with corn tortillas, coffee|
|Lunch: Wife has been making him “healthy lunches,” but he goes most days to taco truck in front of his office.|
|Loves two to three tacos with carnitas or carne asada. Says, “I know I need to cut down on meat so sometimes I have burritos with just rice and refried beans.”|
|Dinner: Wife trying to serve more chicken and fish, but his mother often cooks and makes him antojitos.|
|Father: Type 2 Diabetes, died at age 56 of what you think was a heart attack|
|Mother: Hypertension, obesity|
|Brother: Recently diagnosed with diabetes, high blood pressure, and too much cholesterol in his blood, alive at age 55, lives in Phoenix.|
|Children: All in good health|
|REVIEW OF SYMPTOMS (respond only when asked about the following symptoms):|
|General: You complain of mild fatigue for the last 2 months and note that you feel a bit more tired on your 1- to 2-mile walks (two to three times per week); but no fever, weakness, malaise, or unintended weight loss|
|Skin: No changes and nothing abnormal|
|Eyes: You have noted some blurry vision over the past 5 to 6 months/recently bought a pair of “cheaters” at a local drug store that has only minimally helped; last eye examination > 3 years ago—no concerns per recollection; you have no other symptoms such as eye pain, redness, vision loss, flashing lights/spots, or eye dryness.|
|Ears, nose, mouth, and throat: No symptoms|
|Neck: No symptoms|
|Lungs: No trouble breathing and no cough|
|Heart: No pain or any other symptoms|
|Abdomen: No vomiting or diarrhea, nothing out of the ordinary|
|Urinary: You urinate more often especially during the day for about 3 to 4 months; nothing else.|
|Other: you admit to “possible increased thirst” of recent (few weeks)|
|General: Slightly heavy, but well-appearing, Latino male, looks his stated age in no acute distress|
|Vital Signs: blood pressure = 138/78 mm Hg (left arm, seated, regular cuff), pulse = 82 bpm, respiratory rate = 16 breaths per minute, temperature = 36.9o C. Height = 70 in (177 cm), weight = 195.8 lb (89 kg). Body mass index = 28.4. Waist is 35”.|
|Fasting from 2 days ago, obtained before clinic visit:|
|Result||Reference Range||Result||Reference Range|
|Na||139 mEq/L||(135–145)||Total chol||esterol 258 mg/dL||(< 200)|
|K||4.2 mEq/L||(3.5–5)||LDL||176 mg/dL||(80–210)|
|Cl||100 mEq/L||(95–105)||HDL||43 mg/dL||(30–65)|
|CO2||26 mEq/L||(24–30)||Triglycerides||193 mg/dL||(10–190)|
|BUN||13 mg/dL||(8–18)||Hgb||14.9 g/dL||(14–18)|
|eGFR||90.7 ml/min||(> 60)||RBC||4.47 X 103/mm3||(3.5–5.5)|
|Glu||155 mg/dL||(65–120)||WBC||9.8 X 103/mm3||(4.5–11.0)|
|AST||22 U/L||(9–25)||Platelets||182 X 103/mm3||(150–400)|
|ALT||26 U/L||(7–30)||Urine microalbumin||40 mg/L||(< 30)|
|HgbA1c||7.5%||(goal of < 7%)|
|Point of care testing:|
|Random blood sugar (today) = 216 mg/dL|
|Vision: Rt 20/30, Lt 20/50, Both 20/40|