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.     

Strategies Used by Prehospital Providers to Overcome Language Barriers

Objective: Language barriers are commonly encountered in the prehospital setting but there is a paucity of research on how prehospital providers address language discordance. We sought to identify the communication strategies, and the limitations of those strategies, used by emergency medical services (EMS) providers when confronted with language barriers in a variety of linguistic and cultural contexts. Methods: EMS providers were queried regarding communication strategies to overcome language barriers as part of an international, multi-site, sequential explanatory, qualitative-predominant, mixed methods study of prehospital language barriers. A survey of EMS telecommunicators was administered at dispatch centers in New Mexico (United States) and Western Cape (South Africa). Semi-structured qualitative interviews of EMS field providers were conducted at agencies who respond to calls from participating dispatch centers. Survey data included quantitative data on demographics and communication strategies used to overcome language barriers as well as qualitative free-text responses on the limitations of strategies. Interviews elicited narratives of encounters with language-discordant patients and the strategies used to communicate. Data from the surveys and interviews were integrated at the point of analysis. Results: 125 telecommunicators (overall response rate of 84.5%) and a purposive sample of 27 field providers participated in the study. The characteristics of participants varied between countries and between agencies, consistent with variations in participating agencies’ hiring and training practices. Telecommunicators identified 3rd-party telephonic interpreter services as the single most effective strategy when available, but also described time delays and frustration with interpreter communications that leads them to preferentially try other strategies. In the field, all providers reported using similar strategies, relying heavily on bystanders, multilingual coworkers, and non-verbal communication. Prehospital providers described significant limitations to these strategies, including time delays, breaches of patient confidentiality, and inaccurate interpretation. Participants suggested various resources to improve communication with language-discordant patients. Conclusions: Prehospital providers rely upon similar, informal strategies for overcoming language barriers across a variety of locations, provider types, and linguistic and cultural contexts.     

“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.     

A rapid scoping review of end-of-life conversations with frail older adults in Canada

ObjectiveTo explore what is known about end-of-life (EOL) conversations with frail older adults across all settings including primary care in Canada, and to understand the barriers to, and recommendations for, EOL conversations.Data sourcesComprehensive searches were conducted in CINAHL (EBSCO), Embase (Ovid), MEDLINE (Ovid), AgeLine (EBSCO), Sociological Abstracts (ProQuest), and Applied Social Sciences Index and Abstracts (ProQuest). Searches used text words and subject headings (eg, MeSH, Emtree) related to 3 concepts: frailty, Canada, and EOL conversations.Study selectionTwenty-one English-language articles were selected (ie, 4 reviews, 10 commentaries, 3 quantitative studies, 3 qualitative studies, 1 mixed-methods study) that included information about EOL conversations with frail older adults in the Canadian health care context.SynthesisIn terms of having EOL conversations with frail older adults, this study found that many clinicians do not often and adequately discuss frailty and impending death with their older patients. Moreover, patients and their care partners do not have enough knowledge about frailty and death to make informed EOL decisions, leading to patients choosing more aggressive therapies instead of care focused on symptom management. In terms of barriers to EOL discussions, common barriers included a lack of trust between clinician and patient, inadequate EOL training for clinicians, and ineffective clinician communication with patients and families. Recommendations for improving EOL conversations include regular screening for frailty to prompt conversations about care and the use of an interprofessional approach.ConclusionMore empirical research is needed that uses exploratory methods to shed light on the contextual factors that may act as a barrier to EOL conversations. More research is also needed on the roles and responsibilities of interprofessional teams in screening for frailty and engaging in EOL conversations. Moreover, there is a need to better understand how frail older patients and their families want EOL conversations to unfold and what best facilitates these conversations.     

General practitioners' views on consultations with interpreters: a triad situation with complex issues

Objective

To study a group of general practitioners’ (GPs) views on cross-cultural consultations through interpreters in primary healthcare in Sweden.

Design

Two group interviews and three personal interviews with experienced GPs regarding clinical consultation through interpreters were carried out. The interviews were transcribed and analysed and the text was categorized according to content analysis.

Setting

Primary healthcare.

Subjects

Eight GPs were interviewed.

Main outcome measures

The response and opinions of the GPs.

Results

In the analysis it appeared that an optimal clinical encounter demands an active role by all participants involved in the consultation. The interpreter has to strive after being a stable neutral information bridge, and has a balancing role between the GP and the patient. The GP has to be open to cultural inequalities and recognize consultation through an interpreter as a part of her/his job. The patient needs to be an active and visible participant, not hiding behind the interpreter. Common obstacles and imperfections to reach the best possible triad were discussed. Additionally, practical assets in the encounter were delineated. Accurate physical placing of the persons in the room, adequate length of consultation time, and using the same interpreter from one visit to another were mentioned as factors influencing the outcome of the consultation.

Conclusion

Barriers in cross-cultural communications could originate from all persons involved, the interpreter, the GP, and the patient, as well as from tangible factors. Ways to reduce misunderstandings in GP–patient encounters through interpreters are suggested.     

Consequences of suboptimal communication for patients with limited English proficiency in the intensive care unit and suggestions for a way forward: A qualitative study of healthcare team perceptions

PurposeTo understand the healthcare team's perceptions of the negative consequences of suboptimal communication and their recommendations to improve communication with patients and families who have Limited English Proficiency (LEP) in the Intensive Care Unit (ICU).Materials and methodsWe performed a qualitative study using semi-structured interviews of physicians, nurses, and interpreters from 3 ICUs at Mayo Clinic Rochester, between November 2017 and April 2018.ResultsWe identified 5 consequences of suboptimal communication: 1) Suboptimal assessment and treatment of patient symptoms, 2) Unmet patient and family expectations, 3) Decreased patient autonomy, 4) Unmet end of life wishes and 5) Clinician Distress. Recommendations to improve communication include: 1) Education and training for patients,families, clinicians and interpreters, 4) Greater integration of interpreters into the ICU team 5) Standardized timeline for goals of care conversations with patients and families with LEP.ConclusionsPatients with LEP are at risk of experiencing suboptimal communication with the healthcare team in the ICU. There are several educational and quality improvement strategies that ICUs and institutions can take to mitigate these issues.     

Cancer Caregivers’ Prognostic and End-of-Life Communication Needs and Experiences and their Impact

ContextFamily caregivers of patients with advanced cancer are integrally involved in communications regarding prognosis and end-of-life (EOL) planning and care. Yet little research has examined caregivers’ communication experiences or the impact of these experiences on patients and caregivers at EOL.ObjectivesInvestigate cancer caregivers’ communication experiences and potential impact on patient and caregiver outcomes.MethodsSemistructured interviews with bereaved family cancer caregivers (N=19) about their communication needs and experiences as their loved one approached EOL and died. Audiotaped interviews were transcribed and thematically analyzed for communication-related themes.ResultsCaregivers described fulfilling many important communication roles including information gathering and sharing, advocating, and facilitating—often coordinating communication with multiple partners (e.g., patient, family, oncology team, hospital team). Caregivers reported that, among the many topics they communicated about, prognosis and EOL were the most consequential and challenging. These challenges arose for several reasons including caregivers’ and patients' discordant communication needs, limited opportunity for caregivers to satisfy their personal communication needs, uncertainty regarding their communication needs and responsibilities, and feeling unacknowledged by the care team. These challenges negatively impacted caregivers’ abilities to satisfy their patient-related communication responsibilities, which shaped many outcomes including end-of-life decisions, care satisfaction, and bereavement.ConclusionCaregivers often facilitate essential communication for patients with advanced cancers yet face challenges successfully fulfilling their own and patients’ communication needs, particularly surrounding prognostic and end-of-life conversations. Future research and interventions should explore strategies to help caregivers navigate uncertainty, create space to ask sensitive questions, and facilitate patient-caregiver discussions about differing informational needs.     

Nurses' concerns and practices with using interpreters in the care of Latino patients in the emergency department.

This phenomenological study aimed to describe nursing care of Latinos in the emergency department to determine how care is planned relative to the patient's ethnicity, including linguistic abilities. Unstructured interviews were conducted with 15 registered nurses from four hospitals in the Northwest. Interpreters play a pivotal role in nurses' practices. Nurses' skills with working with interpreters, interpreter availability, engagement, and accuracy enhance or impede effective care. Linguistic differences challenge effective care provision. Culturally competent care requires secure avenues of accurate communication. Administrators must provide nurses with resources that promote culturally competent care, including training with interpreters to facilitate effective communication.     

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.     

Implementing Goals-of-Care Conversations: Lessons From High- and Low-Performing Sites From a VA National Initiative

ContextThe Veterans Health Administration (VA) National Center for Ethics in Healthcare implemented the Life-Sustaining Treatment Decisions Initiative, including policy and practice standards, clinician communication training, a documentation template, and central implementation support to foster advance care planning via goals-of-care conversations for seriously ill veterans in 2014, spreading nationally to other Veterans Health Affairs (VA) sites in 2017.ObjectivesOur goal was to describe the range of early implementation experiences among the pilot sites, and compare them with spread sites that implemented LSTDI about two years later, identifying cross-site best practices and pitfalls.MethodsWe conducted semistructured interviews with 32 key stakeholders from 12 sites to identify cross-site best practices and pitfalls related to implementation.ResultsThree primary implementation themes emerged: organizational readiness for transformation, importance of champions, and time and resources needed to achieve implementation. Each theme's barriers and facilitators highlighted variability in success based on complexity in terms of vertical hierarchy and horizontal cross-role/cross-clinic relationships.ConclusionLearning health care systems need multilevel interdisciplinary implementation approaches to support communication about serious illness, from broad-based system-level training and education to build communication skills, to focusing on characteristics of successful individual champions who listen to critics and are tenacious in addressing concerns.     

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.     

“That is Care That you Just can't fake!”: Identifying Best Practices for the Care of Vietnam Veterans at End of Life

ContextWe reviewed the Veterans Health Administration Bereaved Family Survey's open-ended responses to understand end-of-life (EOL) care best practices for Vietnam and pre-Vietnam Veterans.ObjectivesTo identify 1) recommendations for improved EOL care enhancements for older Veterans, 2) a model of best practices in EOL care for Veterans, and 3) any relevant differences in best practices between Vietnam and prior war eras.MethodsWe examined five years of Bereaved Family Survey data (n = 2784), collected between 2013 and 2017, from bereaved family members of Veterans focusing on 2 open-ended questions: 1) Is there anything else you would like to share about the Veteran's care during his last month of life? 2) Is there anything else you would like to share about how the care could have been improved for the Veteran? Applied thematic analysis identified successes and challenges in the experience of the bereaved of Vietnam and pre-Vietnam era Veterans.ResultsRegardless of war era and death venue, a patient-centered approach to EOL care with readily available staff who could 1) provide ongoing support, comfort, honor, and validation; 2) routinely adjust to the patient's changing needs; 3) and provide clear, honest, timely, compassionate communication was important to the bereaved. Consideration of the uniqueness of Vietnam Veterans is beneficial.ConclusionsPatient-centered EOL care should include assigning a point of contact that follows the patient, educates the family on expectations, ensures the patient's changing needs are met, ensures the family has appropriate support, and communicates updates to the family throughout the patient's care continuum.     

From inside the bubble: migrants�� perceptions of communication with the cancer team

Purpose

Migrants with cancer struggle to communicate with their health care team. This study aimed to identify health-care related unmet needs and communication issues for migrants who develop cancer and factors associated with these challenges. In this paper, the findings related to communication issues are presented.

Patients and methods

Seventy-three cancer patients diagnosed within the previous 3?years and 18 carers, who had migrated to Australia and spoke the designated languages, participated in focus groups or structured interviews. Participants were recruited from ethnic community support organisations, support groups and Oncology clinics within three metropolitan hospitals in two states of Australia. Focus groups and semi-structured interviews were conducted in participants?? own language or English as preferred, audio-taped, transcribed and translated into English and analysed using qualitative methods.

Results

Four themes emerged: (1) cultural isolation, alienation and identification; (2) language and communication difficulties; (3) interpreter issues; and (4) advice for health professionals. Participants, especially those less acculturated, described feeling alone and misunderstood, failing to comprehend medical instructions, being unable to communicate questions and concerns and a lack of consistency in interpreters and interpretation.

Conclusions

Migrants with cancer experience additional challenges to those of native-born patients. Participants provided cogent advice regarding optimal communication with people from their culture. There is clearly a need to develop strategies to increase the cultural competence of care to people from different countries.     

The interpreter: crossing communication barriers between healthcare providers and international patients

As a result of the effects of globalization, cross-racial and cross-cultural marriages have become common phenomena in Taiwan society. The rapid increase in the number of immigrants coming to Taiwan has created a society that will need to confront the impact of the arrival of people from different cultures and the problems associated therewith. These challenges must also be faced by healthcare providers and patients. Since communication is a crucial aspect of healthcare situations, the cost of medical care can be very high and treatment may be of limited effect if communication between patients and healthcare providers is not sufficiently comprehensive. The use of an interpreter is therefore a popular solution to facilitate communication between healthcare providers and patients. The quality of interpretation, however, depends on the training of the interpreter, and will have a great influence on the outcome of health care. Without effective communication, the quality of health care cannot be improved. The question of how to provide continual monitoring of the quality of interpretation and establish a comprehensive training course for interpreters should therefore be further investigated in clinical research.     

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.     

Language barriers and patient safety risks in hospital care. A mixed methods study

IntroductionA language barrier has been shown to be a threat for quality of hospital care. International studies highlighted a lack of adequate noticing, reporting, and bridging of a language barrier. However, studies on the link between language proficiency and patient safety are scarce, especially in Europe. The present study investigates patient safety risks due to language barriers during hospitalization, and the way language barriers are detected, reported, and bridged in Dutch hospital care.MethodsWe combined quantitative and qualitative methods in a sample of 576 ethnic minority patients who were hospitalized on 30 wards within four urban hospitals. The nursing and medical records of 17 hospital admissions of patients with language barriers were qualitatively analyzed, and complemented by 12 in-depth interviews with care providers and patients and/or their relatives to identify patient safety risks during hospitalization. The medical records of all 576 patients were screened for language barrier reports. The results were compared to patients’ self-reported Dutch language proficiency. The policies of wards regarding bridging language barriers were compared with the reported use of interpreters in the medical records.ResultsSituations in hospital care where a language barrier threatened patient safety included daily nursing tasks (i.e. medication administration, pain management, fluid balance management) and patient–physician interaction concerning diagnosis, risk communication and acute situations. In 30% of the patients that reported a low Dutch proficiency, no language barrier was documented in the patient record. Relatives of patients often functioned as interpreter for them and professional interpreters were hardly used.DiscussionThe present study showed a wide variety of risky situations in hospital care for patients with language barriers. These risks can be reduced by adequately bridging the language barrier, which, in the first place, demands adequate detecting and reporting of a language barrier. This is currently not sufficiently done in most Dutch hospitals. Moreover, new solutions to bridge language barriers are needed for situations such as routine safety checks performed by nurses, in which a professional or even informal interpreter is not feasible.     

Application of social ecological model to Taiwanese end-of-life communication and healthcare planning

BackgroundCultural and social backgrounds shape how people regard health, illness and death, and also play a significant role in end-of-life (EOL) decision-making in the face of uncertainty and distress. EOL communication and planning can be complex in a society where families play an important role in decision-making for EOL care in Taiwan.AimThis study aimed to identify the significance of cultural, community, interpersonal and individual determinants of EOL communication and healthcare planning.MethodsA social ecological model was applied to underpin the study. A random sample of 2000 adults aged 20 years or above was selected from the electoral roll in a metropolitan area in southern Taiwan. Adults were told that if they did not wish to participate in the study, they could either return a non-participation form or not complete the questionnaires. Hierarchical multiple regression analyses were used to determine the significance of different societal levels of factors on EOL communication and healthcare planning.FindingsFour hundred and seventy-four valid questionnaires were returned. Hierarchical multiple regression analyses revealed that the models of modified Measures of Public Preferences (p < .0001) were significant, with 22.7% of variance in facilitation, 81.9% of variance in content and 22.9% of variance in support being explained by variables at cultural, community, interpersonal and intrapersonal levels. The model of Advance Directives Attitude Survey (p < .0001) was significant with 25.6% of variance being explained by variables at cultural, community, interpersonal and intrapersonal levels.DiscussionThis study offers empirical evidence embedded within a social ecological perspective of the significance of cultural, social and contextual factors on individuals’ preferences for EOL communication and healthcare planning.ConclusionSuch information is important to enable health professionals to prepare individuals and their families for dealing with challenges related to EOL communication and healthcare.     

Using an interpreter in qualitative interviews: does it threaten validity?

There is an extensive literature on the problem of translating scales for use across cultures, but very little is published on the problems of conducting qualitative interviews in another language with assistance of an interpreter. The aim of this paper is to describe and discuss threats to validity that arise when conducting qualitative interviews using an interpreter. Ten female student nurses in two cities in Lithuania were interviewed about how they perceived their educational program. All interviews were conducted in English with an interpreter. When using an interpreter to conduct interviews, potential threats to validity arise at various points in the interview process. A threat arises when the researcher, whose first language is Swedish, addresses a question in English to the interpreter, another during the translation by the interpreter from English to Lithuanian, and again when the interpreter translates the interviewee's Lithuanian responses to English. In the last situation, the researcher may not know whether the interpreter has summarized and/or modified the responses. To mitigate these problems, the interpreter should not only have the required linguistic abilities, but also be trained in the research field. The researcher has to be aware of these threats to validity and make efforts to meet and limit their effects.