Hospitals have long known that language barriers raise the odds a patient will bounce back to the emergency department. Now, a University of Pennsylvania–led study pinpoints a powerful moderating factor: the nurse work environment.
Examining more than 1.3 million ED visits across 64 New Jersey hospitals, researchers found that limited‑English‑proficient (LEP) patients were 12 per cent more likely to return within 72 hours than English‑proficient peers. But in hospitals where nurses reported the strongest staffing and leadership support, that disparity dropped.
For health‑system executives balancing throughput, quality metrics and compliance requirements, the study offers a concise prescription: pair robust interpreter services with the work‑environment investments nurses say they need. Researchers say the payoff is fewer avoidable revisits, tighter compliance and a smoother patient journey — outcomes that matter as emergency volumes rise and value‑based penalties squeeze margins.
What the study measured — and why it matters
Reducing Disparities in Emergency Department Outcomes for Individuals with Limited English Proficiency: The Nurse Work Environment linked three large data sets: the RN4CAST‑US nurse survey, the American Hospital Association Annual Survey and New Jersey’s statewide ED database.
Patients were tagged as LEP if their preferred language on the intake form was anything other than English. Researchers then determined whether the patient had an unplanned ED revisit within 72 hours, or if the patient left the ED against medical advice (AMA).
“Individuals with LEP experienced higher odds of a 72‑hour ED revisit (adjusted odds ratio (sOR) 1.12) and lower odds of AMA departure (aOR 0.67),” the authors write.
Researchers overlaid those patient outcomes on nurse‑reported work‑environment scores. Hospitals were rated as “poor,” “mixed” or “better” based on staffing adequacy, nurse‑physician collaboration, managerial support and other factors.
The nurse work environment effect
In poor‑scoring hospitals, the probability of a 72‑hour revisit was 4.4 per cent for LEP patients, compared to 2.5 per cent for English speakers. But in “better hospital nurse work environments,” that disparity shrank by 1.3 percentage points.
“Investments in modifiable features of nurses’ work environments… hold promise as a systems‑oriented approach to reduce disparities in avoidable ED revisits among individuals with LEP,” the study concludes.
Why does the work environment matter so much?
The authors note that ED nurses are not only triaging and medicating; they’re also responsible for “acquiring and coordinating necessary interpreter services and technologies.” When staffing is thin or support is weak, interpreter calls get delayed, and critical details can be lost.
Context for hospital leaders
New Jersey may be the study site, but the problem is national.
One in five U.S. residents speaks a language other than English at home, and Section 1557 of the Affordable Care Act requires providers to supply qualified interpreters at no cost to the patient.¹ Yet many hospitals still rely on ad‑hoc solutions — a bilingual orderly, a family member, or worse, a phone on speaker in a crowded bay — all while ED volumes continue to climb.
“Language access is not a ‘nice‑to‑have’ when the metric is bounce‑back visits that drive cost and crowding,” says Tatiana González‑Cestari, PhD, CHI‑Spanish, Equiti’s Director of Language Service Advocacy.
“What this study really shows is that when nurses have the time and resources to deploy professional interpretation quickly, patient comprehension improves, and we see fewer repeat visits.”
When interpretation services are easy to access, providers leverage them. For example, video remote interpreting services like Voyce connect nurses to medically- qualified interpreters in more than 250 languages. It does this incredibly quickly — in an average of less than 20 seconds for most common languages. It’s one way to remove friction from the process, and one less barrier to giving clear, complete instructions the first time.
What “better” looks like on the ground
The five domains in the study’s Practice Environment Scale — staffing adequacy, collegial teamwork, manager support, nurse involvement in decision‑making and a foundation for quality — are familiar to chief nursing officers. Less familiar, perhaps, is how language‑access technology can ease each pain point:
Staffing adequacy: One‑touch video interpretation and very short answer times save minutes nurses valuable time, freeing them for direct care.
Teamwork: The best remote interpretation services feel like an extension of your care team. Real‑time visual cues from a video interpreter help clinicians of every discipline stay on the same page with patients and families.
Manager support: Deploying EHR-integrated interpretation or increasing the number of interpretation devices available signals that leadership values equitable care and supports language access.
Nurse input: Front‑line feedback on which devices work where (triage vs. trauma bay, for example) boosts adoption, as does input on language workflow adjustments.
Quality foundation: Consistent interpreter service use lowers revisit risk, a metric every quality committee tracks.
Maureen Huber, CEO of Equiti, sees the findings as a call to action.
“This data reinforces what we hear from our thousands of healthcare partners: when nurses can access a medically-qualified interpreter in seconds, they close communication gaps before they become clinical gaps,” she says. “Technology alone isn’t enough, but technology in a supportive work environment moves the needle on equity and efficiency.”
The takeaway is clear: language matters, and nurses’ ability to address it is shaped by the conditions in which they work.
Interpretation has to be integrated into daily practice. Voyce works with hospitals to assess where language barriers are most likely to affect care and how interpretation can be built into existing workflows. That includes device placement, staff input, and training.
The goal is to make interpretation easy to access and even easier to use — especially when time is short.
Endnotes
- “Nondiscrimination in Health Programs and Activities,” Section 1557, Affordable Care Act, U.S. Department of Health & Human Services, https://www.hhs.gov/civil-rights/for-individuals/section-1557/fs-limited-english-proficiency/index.html.
- Muir K J, Sliwinski K, Lasater K B. Reducing disparities in emergency department outcomes for individuals with limited English proficiency: The nurse work environment. Nursing Outlook. 2025;73:102318. doi:10.1016/j.outlook.2024.102318.
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