Evaluation of Patient Access to Spanish-Language–Concordant Care on a Postpartum Unit

ObjectiveTo evaluate patient access to Spanish-language–concordant care on a postpartum unit and to identify facilitators and barriers to the use of interpretation services.DesignMixed-methods research study, comprising a cross-sectional chart review from September to December 2019 and semistructured interviews from June to December 2020.Setting/Local ProblemA tertiary academic medical center in the southeastern United States where individuals with limited English proficiency are at risk for poor health outcomes when they are unable to communicate with clinicians in their preferred language.ParticipantsWe conducted a chart review of 50 randomly selected birthing parent–newborn couplets and interviews with 14 inpatient health care team members.MeasurementsThe chart review examined patient characteristics, health care team composition including Spanish language proficiency, length of stay, number of interpreter requests, and time between clinician interpreter requests and interpreter arrival on the unit. Interviews evaluated facilitators and barriers to interpreter use.ResultsAccess to a clinician certified in medical Spanish or an interpreter was offered to 12 of 50 (24%) couplets upon admission to the unit and to 7 of 50 (14%) of couplets for daily maternal and newborn medical rounds. Clinicians reported long and unpredictable wait times to access interpreters, which led them to rely on hand gestures, broken Spanish, and smartphone apps to “get by” when communicating with patients without certified interpretation services. Participants described low usage of interpreters for “noncritical” encounters.ConclusionInterpreters and other forms of Spanish-language–concordant care were underused on the postpartum unit. This deviation from national standards may put families at risk for harm. Recommendations from this study include advancing a culture of respectful care, improving the interpreter request workflow, addressing safe staffing, facilitating direct patient access to interpreters, and providing ongoing evaluation and support.     

The Role of the Interpreter/Doula in the Maternity Setting

Health care organizations often struggle with issues related to communication with patients who have limited English proficiency. Providing quality interpreter services is necessary to comply with regulatory mandates and to provide safe, effective health care. Maternity care presents a unique situation due to the intimate and unpredictable nature of birth. A unique interpreter/doula program in which trained medical interpreters received additional education in labor and postpartum doula skills was tested at a large urban hospital maternity center with a large population of Spanish-speaking patients. Results showed that interpreter/doulas can offer timely, competent care in a variety of maternity situations. They also were cost-effective and associated with increased patient and staff satisfaction.     

“Are They Saying It How I'm Saying It?” A Qualitative Study of Language Barriers and Disparities in Hospice Enrollment

ContextLanguage barriers contribute significantly to disparities in end-of-life (EOL) care. However, the mechanisms by which these barriers impact hospice care remains underexamined.ObjectivesTo gain a nuanced understanding of how language barriers and interpretation contribute to disparities in hospice enrollment and hospice care for patients with limited English proficiency.MethodsQualitative, individual interviews were conducted with a variety of stakeholders regarding barriers to quality EOL care in diverse patient populations. Interviews were audiorecorded and transcribed verbatim. Data were coded using NVivo 11 (QSR International Pty Ltd., Melbourne, Australia). Three researchers analyzed all data related to language barriers, first individually, then in group meetings, using a grounded theory approach, until they reached consensus regarding themes. Institutional review board approval was obtained.ResultsTwenty-two participants included six nurses/certified nursing assistants, five physicians, three administrators, three social workers, three patient caregivers, and two chaplains, self-identifying from a variety of racial/ethnic backgrounds. Three themes emerged regarding language barriers: 1) structural barriers inhibit access to interpreters; 2) variability in accuracy of translation of EOL concepts exacerbates language barriers; and 3) interpreters' style and manner influence communication efficacy during complex conversations about prognosis, goals of care, and hospice. Our theoretical model derived from the data suggests that Theme 1 is foundational and common to other medical settings. However, Theme 2 and particularly Theme 3 appear especially critical for hospice enrollment and care.ConclusionLanguage barriers present unique challenges in hospice care because of the nuance and compassion required for delicate goals of care and EOL conversations. Reducing disparities requires addressing each level of this multilayered barrier.     

Overview of the Advantages and Disadvantages of Professional and Child Interpreters for Limited English Proficiency Patients in General Health Care Situations

Patients from linguistically isolated households with limited English proficiency present a difficult challenge to health care providers. Accurate medical interpretation is vital to providing the highest quality health care and these patients require the assistance of an interpreter to understand and relay information to the provider. The two sources for interpretation assistance to be discussed are the patient's children and professional interpreters. The purpose of this paper is to review the advantages and disadvantages of using professional and child interpreters for patients from linguistically isolated households in general health care situations. Child interpreters may provide more effective assistance for patients with specific dialects; however, the disadvantages such as role reversal in the family are of greater concern. Professional interpreters also have disadvantages, for example concerns regarding patient confidentiality, but they have been determined to be the optimum choice, resulting in fewer errors in translation, higher patient satisfaction, and improved patient outcomes.     

"Her husband doesn't speak much English": conducting a family meeting with an interpreter

A growing percentage of critically ill patients and their families in the United States speak limited English. We present the case of a palliative care consult conducted across language barriers to frame a discussion about the use of interpreters for family meetings, including the evidence for using a professional interpreter, the burden experienced by interpreters involved in end-of-life discussions, potential challenges encountered when conducting a family meeting with an interpreter, and recommended best practices for interpreter use in these settings.     

Interpreter services in pediatric nursing

A critical part of every encounter between a pediatric nurse and a patient is obtaining accurate patient information. Unique obstacles are encountered when patients and their families have little or no understanding of the English language. Federal and state laws require health care systems that receive governmental funds to provide full language access to services. Both legal and ethical issues can arise when caring for non-English-speaking patients. Often, obtaining accurate patient information and a fully informed consent cannot be done without the use of an interpreter. The interpreter informs the family of all the risks and benefits of a specific avenue of care. When inappropriate interpreter services are used, such as when children in the family or other family members act as interpreters, concerns about accuracy, confidentiality, cultural congruency, and other issues may arise. The purpose of this article is to: (a) explore principles related to the use of medical interpreters, (b) examine different models of interpreter services, and (c) identify available resources to assist providers in accessing interpreter services (e.g., books, online resources, articles, and videos). The case study format will be used to illustrate key points.     

Nursing interpreters? Interpreting nurses?

Swiss hospitals are characterized by an increasing diversity, in the sense of personal and social differences such as including origin, gender language, skills, age, lifestyles and social status. Diversity is a challenge for hospitals. It is crucial to language barriers and migration and their clinical consequences. In spite of a trend towards interpreter services "going professional", interpreters are only reluctantly used. This is surprising. In this article we deal with three questions: What are clinical consequences of language barriers? How can language barriers be overcome? Should nurses act as interpreters? The literature available clearly shows that due to insufficient flow of information patients speaking a foreign language tend to receive inadequate care. Also, there is a consensus that patients' relatives acting as ad hoc interpreters are ill-equipped or unsuited to overcome language barriers. Conversely, professional interpreters improve most evidently the quality of care of patients speaking a foreign language. However in clinical everyday life the consistent use of interpreters is not always feasible. Thus, the setting-up of a pool of hospital-based ("internal"), trained bilingual health professionals appears to be an acceptable alternative.     

Problems and consequences in the use of professional interpreters: qualitative analysis of incidents from primary healthcare

The aim of this study was to explore what problems are reported by healthcare professionals in primary healthcare concerning the use of interpreters and what the problems lead to. The study involved a single case in a real-life situation with qualitative content analysis of 60 incident reports written by different healthcare professionals. The main problems documented were related to language, such as lack of the interpreters with proficiency in a particular language, and to organisational routines, with difficulties in the availability of interpreters and access to the interpreter agency. The problems reported led to incorrect use of time and resources, which increased the workload and thus delayed treatment. Other consequences were limited possibilities to communicate and thus consultation was carried out without a professional interpreter, using family members instead. The results highlight the importance of developing good co-operation between the interpreter agency and the primary healthcare centre in order to fulfil the existing policy of using professional interpreters to provide the right interpreter at the right time and guarantee high-quality care.     

Interpretation for Discussions about End-of-Life Issues: Results from a National Survey of Health Care Interpreters

Abstract Background: Communication about end-of-life issues is difficult across language barriers. Little is known about the experience of health care interpreters in these discussions. Objectives: Objectives of this study were to: 1) assess the experiences of healthcare interpreters when interpreting discussions about end-of-life issues; 2) identify interpreter characteristics and experiences that may be associated with improved satisfaction and comfort with interpreting these discussions; and 3) describe interpreter training needs. Methods: The study utilized an electronically administered survey distributed nationally to health care interpreters in the United States. One hundred and forty-two health care interpreters participated. Measurements included general experiences, attitudes, and perceived training needs when interpreting discussions about end-of-life issues. Results: Most respondents had received a certificate in interpretation (71%, 101/142), completed more than 40 hours of training (89%, 127/142), and had more than 5 years of interpreting experience (65%, 93/142). Overall, 85% (121/142) of respondents had interpreted discussions about end-of-life issues and most interpreted multiple discussions per week. Of those interpreters who had experience with these discussions, the majority (85%, 103/121) reported feeling comfortable, but only half (48%, 58/121) reported that these discussions usually went well. Interpreters who felt clear about their role were more likely than interpreters who did not feel clear about their role to think that discussions went well (51% [57/112] versus 11% [1/9], p=0.02) and to feel comfortable interpreting (88% [98/112] versus 56% [5/9], p=0.01). Eighty percent (97/121) of respondents with experience in end-of-life discussions were personally interested in more specific training for these discussions. Attitudes and perceived training needs did not differ by interpreter demographics or qualifications. Conclusions: The majority of interpreters have experience with end-of-life discussions but, independent of interpreter training and experience, only half report that these discussions usually go well. Interpreters want and may benefit from targeted educational interventions that could improve the quality of care for vulnerable patients and families in these difficult situations. Health systems and interpreter certification programs should incorporate specific training on how to interpret discussion about end-of-life issues.     

The impact of language barriers & interpreters on critical care patient outcomes

BackgroundIn a multicultural society, the impact of language proficiency and interpreter use on critical care patient outcomes is unknown.ObjectiveTo investigate the relationship between English language preference, requirement for an interpreter and in-hospital mortality amongst non-elective intensive care unit (ICU) patients.MethodAdult patients admitted to all 23 public ICUs within the state of Victoria, Australia from July 2007 to June 2018, were extracted from The Australian New Zealand Intensive Care Society Adult Patient Database. De-identified patient data was matched using probabilistic methods and statistical linkage keys to the Victorian Admitted Episodes Database. Patients were classified into one of three groups: ‘English preferred’, ‘English not preferred’ and ‘Interpreter required’.Results126,891 ICU admissions were analysed, of whom 3394 (3%) were in the ‘English not preferred’ group and 6355 (5%) in the ‘Interpreter required’ group. Compared to the ‘English preferred’, both the ‘English not preferred’ and ‘Interpreter required’ groups were older, had more co-morbidities and higher severity of illness scores. In-hospital mortality was 13.1% in the ‘English preferred’ group, 19.6% in the ‘English not preferred’ group and 16.7% in the ‘Interpreter required’ group. However, after adjusting for sex, severity of illness and socio-economic status, the ‘English not preferred’ group remained with a higher risk adjusted mortality (OR 1.21, 95%CI 1.07–1.36, P = 0.002), whereas the ‘Interpreter required’ group had a lower adjusted risk of mortality (OR 0.81, 95%CI 0.74–0.89, P < 0.001).ConclusionBeing identified as having a requirement for an interpreter was associated with improved outcomes for adults admitted to public hospital ICUs in Victoria. Interpreter services should be more readily available in the hospital setting. It is recommended that patients, family members and clinicians actively use interpreter services when English is not the preferred language of an ICU patient.     

Interpreter services in emergency medicine

Emergency physicians are routinely confronted with problems associated with language barriers. It is important for emergency health care providers and the health system to strive for cultural competency when communicating with members of an increasingly diverse society. Possible solutions that can be implemented include appropriate staffing, use of new technology, and efforts to develop new kinds of ties to the community served. Linguistically specific solutions include professional interpretation, telephone interpretation, the use of multilingual staff members, the use of ad hoc interpreters, and, more recently, the use of mobile computer technology at the bedside. Each of these methods carries a specific set of advantages and disadvantages. Although professionally trained medical interpreters offer improved communication, improved patient satisfaction, and overall cost savings, they are often underutilized due to their perceived inefficiency and the inconclusive results of their effect on patient care outcomes. Ultimately, the best solution for each emergency department will vary depending on the population served and available resources. Access to the multiple interpretation options outlined above and solid support and commitment from hospital institutions are necessary to provide proper and culturally competent care for patients. Appropriate communications inclusive of interpreter services are essential for culturally and linguistically competent provider/health systems and overall improved patient care and satisfaction.     

Does English proficiency impact on health outcomes for inpatients undergoing stroke rehabilitation?

Purpose: To determine whether English proficiency and/or the frequency of interpreter use impacts on health outcomes for inpatient stroke rehabilitation. Method: Study design: Retrospective case–control study. Participants: People admitted for inpatient stroke rehabilitation. A high English proficiency group comprised people with native or near native English proficiency (n?=?80), and a low English proficiency group comprised people who preferred a language other than English (n?=?80). Outcome measures: Length of stay (LOS), discharge destination and Functional Independence Measure (FIM). Results: The low English proficiency group showed a greater improvement in FIM from admission to discharge (p?=?0.04). No significant differences were found between groups in LOS, discharge destination and number of encounters with allied health professionals. Increased interpreter usage improved FIM efficiency but did not significantly alter other outcomes. Conclusion: English proficiency does not appear to impact on health outcomes in inpatient rehabilitation with a primarily in-house professional interpreter service. However, there is a need for a larger powered study to confirm these findings.

• Implications for rehabilitation

• People with low English proficiency undergoing inpatient stroke rehabilitation in a setting with a primarily in-house professional interpreter service, achieved similar outcomes to those with high English proficiency irrespective of frequency of interpreter usage.

• A non-significant increase of 4 days length of stay was observed in the low English proficiency group compared to the high English proficiency group.

• For patients with low English proficiency, greater change in Functional Independence Measure efficiency scores was observed for those with higher levels of interpreter use relative to those with low interpreter use. Clinicians should optimise use of interpreters with patients with low English proficiency when possible.

     

Language barriers and qualitative nursing research: methodological considerations

Aim:  This review of the literature synthesizes methodological recommendations for the use of translators and interpreters in cross-language qualitative research.
Background:  Cross-language qualitative research involves the use of interpreters and translators to mediate a language barrier between researchers and participants. Qualitative nurse researchers successfully address language barriers between themselves and their participants when they systematically plan for how they will use interpreters and translators throughout the research process. Experienced qualitative researchers recognize that translators can generate qualitative data through translation processes and by participating in data analysis. Failure to address language barriers and the methodological challenges they present threatens the credibility, transferability, dependability and confirmability of cross-language qualitative nursing research. Through a synthesis of the cross-language qualitative methods literature, this article reviews the basics of language competence, translator and interpreter qualifications, and roles for each kind of qualitative research approach. Methodological and ethical considerations are also provided.
Conclusion:  By systematically addressing the methodological challenges cross-language research presents, nurse researchers can produce better evidence for nursing practice and policy making when working across different language groups. Findings from qualitative studies will also accurately represent the experiences of the participants without concern that the meaning was lost in translation.     

Missed Opportunities When Communicating With Limited English-Proficient Patients During End-of-Life Conversations: Insights From Spanish-Speaking and Chinese-Speaking Medical Interpreters

ContextResearch has shown that using medical interpreters in language-discordant patient-provider encounters improves outcomes. There is limited research evaluating the views of medical interpreters on best interpreter practices when they are used to break bad news or participate in end-of-life (EOL) conversations.ObjectivesTo develop insights from medical interpreters about their role when interpreting discussions regarding EOL issues, identify practices interpreters perceive as helping to improve or hinder patient-provider communication, and obtain suggestions on how to improve communication during EOL conversations with Spanish-speaking and Chinese-speaking patients.MethodsSemistructured interviews were conducted with Spanish or Chinese medical interpreters. Participants were recruited until thematic saturation was reached. Twelve interviews were conducted, audiotape recorded, transcribed, and analyzed using standard qualitative methods.ResultsSix major themes were identified: medical interpreters' perceived comfort level during EOL interpretation; perception of interpreter role; communication practices perceived as barriers to effective communication; communication practices felt to facilitate effective communication; concrete recommendations how to best use medical interpreters; and training received/perceived training needs.ConclusionMedical interpreters provide literal interpretation of the spoken word. Because of cultural nuances in Chinese-speaking and Spanish-speaking patients/family members during EOL conversations, medical interpreters can translate the meaning of the message within a specific cultural context. Conducting premeetings and debriefings after the encounter are potentially important strategies to maximize communication during EOL conversations.     

Being a gift- Multilingual healthcare professionals in neonatal care

BackgroundParents said that they sometimes wished they had a multilingual physician as an interpreter, because the physician would understand the child's care and treatment and share a language with the parents.AimTo understand and describe the lived experience of multilingual neonatal healthcare professionals dealing with interpreting in their workplace, performing as interpreters in addition to their regular work.MethodsInterviews with multilingual neonatal healthcare professionals and analysed using a phenomenological reflective lifeworld approach.ResultsMultilingual healthcare professionals understood the interpreting experience as being a gift, comprising three themes: feeling satisfaction – happiness from helping workplace colleagues; identifying with families – empathy from having been in the same situation; and expected to be available – colleagues expected them to provide interpreting services.ConclusionThis study found that it is common in neonatal care to use multilingual healthcare professionals to interpret communication with parents when language barriers exist.     

Language Barriers as a Reported Cause of Prehospital Care Delay in Minnesota

Objective. Although anecdotal reports exist, the frequency of language barriers encountered between EMS providers andpatients/families in the prehospital environment remains unknown. The purpose of this study was to determine the frequency of EMS provider-reported perceived delays in care due to language barrier andto characterize the nature of calls involved.Methods. Retrospective analysis of the Minnesota State Ambulance Reporting system (MNSTAR) database, a mandated statewide EMS data collection tool. All EMS run reports submitted between January 1, 2004, andJune 30, 2005, were reviewed to identify instances of reported treatment delay secondary to a language barrier.Results. During the 18-month study period, 629,738 patient encounter reports were submitted to MNSTAR, of which 2,052 identified treatment delays secondary to language. The rate of language barrier care delays in the state of Minnesota is 3.3 per 1,000 prehospital patient encounters.Conclusion. EMS responses troubled by delays in care secondary to language barriers represent a small percentage of total runs in Minnesota. However, approximately 1,370 cases per year occur.     

Impact of Language Barrier on Acute Care Medical Professionals Is Dependent Upon Role

Communication with patients is essential to providing quality medical care. The study was conducted to evaluate the effects of language barriers on health care professionals. It is hypothesized that these language barriers are commonly perceived by health care professionals and they are a source of workplace stress in acute care environments. We designed and distributed a survey tool of staff experiences and attitudes regarding the English-Spanish language barrier among patients in an acute care surgical environment of a tertiary medical center. Responses were anonymous, stratified by professional role and comparisons made using paired t tests. Sixty-one nurses and 36 physicians responded to the survey. Overall, 95% of nurses reported that the language barrier was an impediment to quality care, whereas 88% of physicians responded similarly (P = .0004). More nurses than physicians report experiencing stress (97% vs. 78%) and the degree of stress appears to be greater for nurses (P < .0001). The basis of stress was unique between the two groups. This study demonstrates that acute care hospital medical professionals perceive language barriers as an impediment to quality care delivery and as a source of workplace stress. Nurse and physician perceptions differ; therefore, strategies to address these language barriers should be specific to those professional roles. These barriers create a void in health care quality and safety that has effects on health care professionals.     

Medical language proficiency: A discussion of interprofessional language competencies and potential for patient risk

In increasingly multilingual healthcare environments worldwide, ensuring accurate, effective communication is requisite. Language proficiency is essential, particularly medical language proficiency. Medical language is a universal construct in healthcare, the shared language of health and allied health professions. It is highly evolved, career-specific, technical and cultural-bound—a language for specific purposes. Its function differs significantly from that of a standard language. Proficiency requires at minimum, a common understanding of discipline-specific jargon, abstracts, euphemisms, abbreviations; acronyms. An optimal medical language situation demands a level of competency beyond the superficial wherein one can convey or interpret deeper meanings, distinguish themes, voice opinion, and follow directions precisely. It necessitates the use of clarity, and the ability to understand both lay and formal language—characteristics not essential to standard language. Proficiency influences professional discourse and can have the potential to positively or negatively affect patient outcomes. While risks have been identified when there is language discordance between care provider and patient, almost nothing has been said about this within care teams themselves. This article will do so in anticipation that care providers, regulators, employers, and researchers will acknowledge potential language-based communication barriers and work towards resolutions. This is predicated on the fact that the growing interest in language and communication in healthcare today appears to be rested in globalization and increasingly linguistically diverse patient populations. Consideration of the linguistically diverse healthcare workforce is absent. An argument will be posited that if potential risks to patient safety exist and there are potentials for disengagement from care by patients when health providers do not speak their languages then logically these language-based issues can also be true for a care team of mixed linguistic backgrounds. Members may disengage from each other or adverse events may occur as a result of misunderstanding or other language-based confounds. While the greater goal of the article is to address the issues of medical language across languages, English and medical English are used to illustrate points. Questions will be posed to stimulate thought and identify a need for research. Recommendations include collaboration between the health and language disciplines.