Abstract
Background and Purpose As the Hispanic population continues to expand in the United States, health professionals increasingly may encounter people who speak Spanish and have limited English proficiency. Responding to these changes, various health profession educators have incorporated Spanish language training into their curricula. Of 12 doctor of physical therapy (DPT) programs identified as including elective or required Spanish courses, the program at The University of Texas at El Paso is the only one integrating required Spanish language training across the curriculum. The purpose of this case report is to describe the development, implementation, and preliminary outcomes of the evolving educational model at The University of Texas at El Paso.
Case Description The University of Texas at El Paso is situated immediately across the border from Mexico. Responding to the large population with limited English proficiency in the community, faculty began to integrate required Spanish language training during a transition from a master-level to a DPT curriculum. The Spanish language curriculum pillar includes a Spanish medical terminology course, language learning opportunities threaded throughout the clinical courses, clinical education courses, and service-learning. Forty-five DPT students have completed the curriculum.
Outcomes Assessment methods were limited for early cohorts. Clinically relevant Spanish verbal proficiency was assessed with a practical examination in the Spanish course, a clinical instructor–rated instrument, and student feedback. Preliminary data suggested that the model is improving Spanish language proficiency.
Discussion The model still is evolving. Spanish language learning opportunities in the curriculum are being expanded. Also, problems with the clinical outcome measure have been recognized. Better definition of intended outcomes and validation of a revised tool are needed. This report should promote opportunities for collaboration with others who are interested in linguistic competence.
The rising Hispanic population accounted for more than 50% of the population growth in the United States between 2000 and 2010.1 Although still living in large numbers in locations with established Hispanic communities, such as Texas and California, people of Hispanic descent are increasingly migrating and settling across the country.2 Between 1980 and 2000, the Hispanic population in half of the states grew by more than 200% or by more than 200,000 Hispanic residents.2
Predictably, given these nationwide demographic changes, Spanish is by far the most commonly spoken language in the United States after English.3 According to 2011 data, an estimated 43.7% of Spanish speakers speak English “less than ‘very well.’”3 Of the total population with limited English proficiency (LEP), 65% speak primarily Spanish.4 The Pew Commission predicts that by 2050, 82% of the growth in the US population will arise from immigration,5 indicating that health care professionals likely will encounter clients with LEP.
The National Culturally and Linguistically Appropriate Services (CLAS) Standards in Health and Health Care guide professionals who serve clients with LEP. The linguistic element of the CLAS Standards is meant to ensure that services are provided in the client's preferred language through trained interpreters or health care professionals who are competent in that language. These standards are envisioned to improve quality of care and decrease health care disparities.6
Communication barriers can contribute to health care disparities and poor health literacy.7–10 Health literacy includes the ability to understand and interpret written materials and spoken information associated with health and function.7 Regardless of language concordance between clients and health care professionals, poor health literacy is associated with fewer preventative screenings, greater use of emergency care, increased hospitalizations, misunderstandings about medication use, and nonadherence to medical regimens.7 Poor health literacy also is linked to activity limitations and poor physical functioning.11
Responding to changing demographics, the CLAS Standards, and health care disparities among people with LEP, educators from various health professions have incorporated clinically relevant Spanish language training into their respective curricula.12–20 Some institutions provided only single Spanish language courses12,16 or a week-long Spanish immersion within the United States.13 For example, Frasier et al described a 6-day mini-immersion program offered to 8 medical interns.13 The goals were to learn basic greetings and “survival skills”13(p293) (eg, asking the patient to speak more slowly), obtain a basic history, give simple commands during the physical examination, and provide basic instruction regarding medication frequency. Although all interns improved their scores on written tests, there was no assessment of verbal proficiency.13 Others offered more extensive Spanish language learning opportunities,15,17 such as an international immersion rotation.15 However, these were elective14,15,17 and, in some cases, were available only to intermediate/advanced Spanish speakers.14,15
Through professional networking, we identified one example of a program in which medical students at any proficiency level are required to participate in extensive Spanish language learning opportunities. Similar to earlier examples,12,16 The Texas Tech University Paul L. Foster School of Medicine provides a Spanish medical terminology course. However, the school also integrates Spanish practice across the clinical skills curriculum (Gordon Woods, MD, MPH; written communication; November 2013). The school has not yet documented its model or outcomes in the literature.
We also discovered examples of language training efforts in the physical therapy literature.18–20 The first article described a pilot study of an elective Spanish course in the Master of Physical Therapy curriculum at our own institution.18 Eighteen students participated in 12 hours of Spanish instruction focused on clinically relevant vocabulary. The results of written tests before and after the course indicated that students with various proficiency levels (including a native speaker) demonstrated significant improvements. In the second study, Masin and Tischenko19 reported significant differences in the results of written tests before and after a 6-session elective Spanish course focused on clinical content. Lastly, Gazi and Oriel20 described a domestic service-learning experience in which students applied content from an earlier Spanish course. The researchers in the latter study did not measure language proficiency. None of the authors in these 3 studies reported measures of verbal proficiency.
Although limited examples were found in the physical therapy literature, we networked with colleagues and explored the Internet to identify other programs that offer Spanish language training. These efforts included performing Google searches, posting a query on the listserves of the American Physical Therapy Association's Education Section and the Global Health Special Interest Group, and having a research assistant systematically search curricula on all physical therapist education program websites to identify Spanish courses. Through these searches, we found 8 programs that presently offer elective Spanish courses or allow students to take Spanish to fulfill elective credits: Columbia University (New York), Des Moines University (Iowa), Emory University (Georgia), Franklin Pierce University (New Hampshire), Pacific University (Oregon), Samuel Merritt University (California), University of New Mexico, and University of Wisconsin–Madison. The University of Miami (Florida) does not currently offer elective Spanish courses but expects to in the future (Helen Masin, PT, PhD; written communication; July 2013).
Four universities (including our own) require physical therapist students to participate in a Spanish language course. These are Florida Gulf Coast University, Lebanon Valley College (Pennsylvania), University of Texas at El Paso, and University of Texas Medical Branch at Galveston. Faculty at these institutions reported that they did not integrate mandatory Spanish language practice in other portions of their curricula.
Because we did not contact the program director of every doctor of physical therapy (DPT) program, we acknowledge that our identification of elective and mandatory Spanish language learning opportunities may be incomplete. However, to our knowledge, the physical therapist education program at the University of Texas at El Paso is the only one integrating required Spanish language training across the curriculum. Specifically, Spanish is a curriculum pillar, and this pillar includes a Spanish medical terminology course, language learning opportunities threaded throughout the clinical courses, clinical education courses, and service-learning. The purpose of this case report is to describe the development, implementation, and preliminary outcomes of this educational model. Additionally, we discuss the ongoing evolution of the program and explain future steps.
Target Setting
The University of Texas at El Paso is situated immediately across the border from Cuidad Juarez, Mexico. Although it is projected that 29% of the US population will be Hispanic by 2050,5 81.2% of the El Paso County population currently is Hispanic.21 The majority (72.4%) of the county population speaks Spanish at home.22 Of the households with Spanish speakers, 25.5% were categorized as not having a member age 14 and older who “speaks English only or speaks English ‘very well.’”23
Although not exactly mirroring the county demographics, a high proportion (47.6%) of the first DPT cohort was Hispanic. Similarly, 54% (40/74) of the current students identified their ethnic origin as Hispanic. However, the majorities of both Hispanic and non-Hispanic students are not proficient in Spanish. Given this language incongruence between the students and at least one-quarter of the population of the region,23 the core faculty recognized the importance of requiring Spanish language training when the program transitioned from a Master of Physical Therapy curriculum to a DPT curriculum.
Development of the Process
The program curriculum committee, composed of all 6 core faculty members, began DPT curriculum development 2 years before the entry of the first DPT cohort. The committee members unanimously agreed during the first year of planning to require a Spanish medical terminology course in the new curriculum. This decision was influenced, in part, by the positive results noted in a pilot study18 of an elective Spanish course offered several years earlier. Additionally, local clinical instructors and employers emphasized that graduates should communicate in Spanish to work effectively in the border region.
The next year, all 6 core faculty members began a series of meetings with an external curriculum consultant. Using expertise gained from a PhD in higher education and 28 years as a physical therapy educator, she guided the committee members to consider how to best align curriculum content and program goals with the mission to serve the community. In response, the core faculty members decided to expand Spanish language training opportunities across the new curriculum.
One faculty champion (with intermediate Spanish proficiency) advocated for this change, and no core faculty members objected. Although the composition of the core faculty has changed since the process began, the same 2 people have led the curriculum enhancement. In the third year of implementation of the linguistic pillar, a newly arrived program director joined the efforts. Throughout the process, all core faculty members have been involved in meetings about the curriculum. Table 1 summarizes core faculty demographics and Spanish-related faculty development.
Demographics of Core Faculty During the First 3 Years of Development of the Spanish Curriculum Pillar
Efforts to develop the curriculum pillar were limited by the competing demands of the new DPT curriculum. A thorough literature review and Internet search related to Spanish language training in the health care professions was not conducted until the third year of implementation. Searches for additional appropriate resources have been ongoing since then.
Application of the Process
Development of the Spanish Language Curriculum Pillar
The Spanish language curriculum pillar is divided into 4 components: a Spanish medical terminology course, language learning opportunities threaded throughout the clinical courses, clinical education courses, and service-learning. Table 2 provides an overview of the current and planned placements of these components in the curriculum and sample learning activities. At this point, 2 DPT cohorts have completed the curriculum, and 2 cohorts are in progress.
Summary of Current and Planned Spanish Language Training Opportunities by Semester, Course, and Frequency of Exposure to Spanish Languagea
Development and Application of Pillar Components
Spanish medical terminology course.
The previous program director was primarily responsible for designing the Spanish medical terminology course in the DPT curriculum. She chiefly used the lessons learned from her prior pilot study.18 That study demonstrated that all students improved their clinical Spanish language proficiency in an elective course (with 1 section) taught by a language instructor. However, intuitively, the program director thought that physical therapists who are native Spanish speakers would know better what vocabulary is most relevant to teach than a Spanish language instructor. She also predicted that at least 2 sections (beginner and intermediate/advanced) of the course would enhance learning (Mary Carlson, PT, PhD; written communication; July 2013).
The course was structured with a physical therapy–specific Spanish language text.24 Physical therapists who are native Spanish speakers have been the course instructors. The same instructor has always taught students at the beginner level. For intermediate/advanced Spanish speakers, a second instructor taught the first 2 years, and a third person instructed the next 2 cohorts. Faculty-to-student ratios have ranged from 1:10 to 1:16.
Originally, course faculty members interviewed all students in Spanish and placed them in 1 section. Currently, students first self-rate on a scale from 0 to 10 (with “0” being no ability to speak Spanish and “10” being native speaker proficiency). Students with ratings of 0 to 3 are placed in the beginner section, and those with ratings of 8 to 10 are placed in the intermediate/advanced section. Course instructors briefly interview students with ratings of 4 to 7 and assign them to the most appropriate section on the basis of their Spanish verbal proficiency.
Students attend 2-hour classes weekly for 7 weeks in the second semester of the program. Instructors focus on experiential learning activities, including role playing between students. Patients, staff, or students who speak Spanish serve as simulated patients for scenarios in which students practice basic examinations and interventions. Students complete a written quiz each week and must pass a practical examination in week 8.
Clinical courses.
The 4 core faculty members who taught clinical courses to the first DPT cohort committed to including at least one opportunity for students to practice speaking Spanish in each clinical course. The faculty members were tasked with determining how to incorporate Spanish into their courses (Tab. 2). However, collectively they agreed that students should focus on practicing common clinically relevant tasks.
Students practice selected examinations or interventions in some clinical courses a minimum of 1 time per semester per course. Students who are native Spanish speakers and other advanced students serve as simulated patients and assist with educating less proficient students. Faculty members with poor Spanish proficiency have the option to arrange assistance from clinical faculty members who are bilingual. Students are encouraged to use the reference guides found in the back of their textbook24 as “cheat sheets” and to use other Spanish resources, such as mobile applications.
Spanish has not yet been incorporated into all of the clinical courses consistently, primarily because of core faculty changes. For recently hired or associate faculty, the priority is ensuring that foundational clinical content is delivered. However, we are working with all faculty members to add permanent Spanish content to clinical courses. The goal is that by the entry of the sixth DPT cohort, Spanish language learning will be integrated in 10 clinical courses (Tab. 2).
Clinical education courses.
Students are placed in clinical sites by the Director of Clinical Education. Students submit their preference for placement on the basis of site availability. All students are placed in local sites for part-time integrated clinical experiences in the third semester. With the exception of military sites, all local clinical sites offer students opportunities to practice Spanish.
Recognizing that students ultimately need to demonstrate language proficiency in clinics, we developed a Spanish language–related assessment (Appendix) for use during clinical rotations. During part-time and 3 full-time 8-week clinical experiences, students are assessed with the Physical Therapist Manual for the Assessment of Clinical Skills (PT MACS).25 Therefore, we created our assessment (Appendix) using the format of the PT MACS as a guide. Although students do not use the PT MACS during their 12-week internship, they continue to use the same Spanish language–related assessment used in the earlier clinical experiences.
The Director of Clinical Education educates clinical instructors during midterm visits, either by phone or in person, with regard to evaluating Spanish communication skill. The skill is rated at midterm and at the completion of each full-time clinical experience. At local sites, most clinical instructors have the Spanish proficiency to rate students or have access to a colleague who is bilingual and can assist in the assessment. However, in some cases, qualified assessors are not available. Failure to meet Spanish language–related criteria does not affect a student's course grade.
We realized from the beginning that this assessment likely was overly simplistic, and we implemented the tool without formally testing its validity and reliability. However, we determined that it was most important to try something, and we expected to revise the measure when we gained more insight and possibly external funding for a pilot study.
Service-learning.
All students participate in local service-learning activities during the first and second semesters of the curriculum for a minimum of 10 hours per semester. Course faculty members seek to build relationships between students and 6 partner organizations. Therefore, unless there are extenuating circumstances, each student is expected to complete all hours at the same site. The organizations serve both clients who speak English and clients who speak Spanish and have LEP.
Students also have the opportunity to apply for an elective interdisciplinary global health course with a 10-day international service-learning component in Guatemala.26 This course offers students daily opportunities to work on their Spanish proficiency while working with staff and patients who speak Spanish at a health center. Additionally, students may elect to participate in 20 hours of Spanish instruction in a local language school during this component.
Outcome
Spanish Medical Terminology Course
One hundred percent of the students in the first 3 cohorts have passed their practical examination in the Spanish medical terminology course. The examination included demonstrating the ability to use at least basic Spanish to complete a simple patient examination with basic tests and measures. In student course evaluations in the first 3 cohorts, the average overall course rating was 4.5 of 5 (with 5 being “excellent”); ratings ranged from 3.5 to 5. Additionally, 84.0% (42/50) of the written comments were positive.
Clinical Courses
To date, each cohort has practiced Spanish in 4 or 5 clinical courses. Students' progress with communicating in Spanish during each clinical course was not formally assessed. Rather, our plan was to develop an assessment tool that can be used to measure their progress at selected points across the curriculum. In general, students enthusiastically practiced Spanish during classes. Informal student feedback was very positive. For example, a student documented this reflection after an encounter with a patient who spoke Spanish during her first full-time clinical experience: “This made me feel so successful with a complete THA [total hip arthroplasty] treatment in Spanish and with no Spanish speaker's help! This is when I thought, ‘Thank God for all the times we practiced our scenarios in Spanish in class.’”
Clinical Education Courses
The majority of the students had opportunities to work with clients who spoke Spanish at each of their 3 full-time 8-week clinical experiences (Tab. 3). Of those at local nonmilitary clinical sites, 100% had regular opportunities to practice Spanish.
Percentages of Physical Therapist Students Working with Clients Who Spoke Spanish During Their Full-Time 8-Week Clinical Experiencesa
Clinical instructors assessed students' proficiency in the Spanish language skill (Appendix). In the first and second cohorts, 90.5% (19/21) and 91.7% (22/24), respectively, of the students achieved the skill by the end of their clinical training. Of students who did not achieve the skill, all spent a marked amount of time at sites with small numbers of patients who spoke only Spanish.
Service-Learning
Although service-learning data were not collected for the first 3 cohorts, 100% of students in the fourth cohort reported that they practiced Spanish at their local service-learning sites. Additionally, students in 4.8% (1/21) of the first cohort, 8.3% (2/24) of the second cohort, and 5.3% (1/19) of the third cohort participated in the elective international service-learning experience, where they used Spanish daily. Of the 2 students who were not native Spanish speakers, both chose to participate in intensive Spanish language training in Guatemala; 1 selected semiprivate lessons (1 instructor to 2 students), and 1 chose private lessons (1:1). In the fourth cohort, 14.8% (4/27) are scheduled to participate.
Overall Curriculum
We have included graduate outcomes related to Spanish linguistic competence in our program assessment plan. The relevant data will be collected through graduate and employer surveys; data for our first DPT cohort are not yet available. However, during the final curriculum review, we asked this cohort to ascertain the strengths of the overall DPT curriculum through a consensus-building exercise. They identified the Spanish language curricular pillar as 1 of the 9 unranked strengths.
Discussion
The purpose of this case report was to describe the development, implementation, and preliminary outcomes of an evolving educational model that integrates Spanish language learning activities across a DPT curriculum. We acknowledge many shortcomings in our process of developing and implementing the model. However, given the limited guidance found in the physical therapy literature, we expect that the progress and flaws of our process will be instructive to other DPT programs that are currently incorporating or will incorporate Spanish in their curricula. Because of variability in outcome measures in the existing physical therapy literature, we cannot compare our preliminary outcomes directly with those of other reports. Researchers18,19 previously examined the outcomes of an elective Spanish course with written tests before and after the course to document improvements in knowledge. Given our aim to develop verbal proficiency, we focused on an end-of-course practical examination in the Spanish course. However, incorporating written tests before and after the course would enhance our ability to document learning outcomes.
Also unlike those researchers,18,19 we developed an outcome measure (Appendix) aimed at assessing verbal proficiency in a clinical setting. However, the major limitation of our current model is that we failed to formally evaluate the tool before implementation; therefore, we lack validity and reliability data. In fact, we soon observed problems with the measure while using it in clinics, and we initiated plans to revise it.
A second and related major limitation is that we did not adequately operationally define realistic outcomes. As medical educators stated,12 the goal is for graduates to be at least “functionally bilingual.” However, like them, we did not clearly define the term. The solution may be delineating common tasks that contribute to a physical therapist being functionally bilingual and then ranking them by complexity. Outlining tasks in this way may lead to a more uniform definition of language fluency among physical therapists. This approach is in alignment with the recommendation of Diamond and Reuland,27 who called for determining a standardized strategy for assessing language fluency among physicians.
At this point, we are shifting our assessment from clinics to simulated laboratory settings with evaluators possessing consistent Spanish proficiency. We are revising the original measure, and we plan to perform a formal pilot study this year to assess its face validity and interrater reliability. This change is intended to improve uniformity in assessment, because our students do not always have clinical instructors who are bilingual. Additionally, it will allow for repeated measurements at set points in the curriculum.
Until we have a valid and reliable measure of Spanish verbal proficiency in a clinical context, we will be unable to make fully informed decisions about the Spanish curriculum component. However, formal and informal feedback from students and their clinical instructors suggests that we are moving in the right direction. Also, given that employers were a stimulus for the curriculum change, we are eager to analyze data from employer surveys for the first DPT cohort.
Finally, the development of a valid and reliable measure of Spanish verbal proficiency will allow for future research to compare outcomes of different models. We hope that this case report promotes opportunities for discussion and collaboration with other educators and researchers to determine optimal models for promoting linguistic competence.
Appendix.
Tool Used to Assess Students' Spanish Language Proficiency in Clinics
Footnotes
Dr Pechak and Dr Diaz provided concept/idea/project design. Dr Pechak and Dr Dillon provided writing. Dr Dillon provided data collection. Dr Diaz provided project management and consultation (including review of the manuscript before submission). The authors express their gratitude to the following people: retired Program Director, Dr Mary Carlson, for leading the development of the original required Spanish course for the DPT curriculum; the external consultant, Dr Darlene Sekerak, for guiding the authors toward more optimally aligning their curriculum with their mission and vision; Ryan Sorenson for searching the program websites; and especially the past and current faculty of their Spanish course for teaching and important input into course design—Sandra Terrazas, PT, MBA, Joaquin Santillan, PT, and Curtis Hartvigsen, PT.
The model described in this case report was presented in a platform presentation at the International Sun Conference on Teaching and Learning; March 1, 2013; El Paso, Texas.
- Received August 7, 2013.
- Accepted July 19, 2014.
- © 2014 American Physical Therapy Association
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