Inpatient Communication Barriers and Drivers When Caring for Limited English Proficiency Children
BACKGROUND: Achieving effective communication between medical providers and families with limited English proficiency (LEP) in the hospital is difficult.
OBJECTIVE: Our objective was to identify barriers to and drivers of effective interpreter service use when caring for hospitalized LEP children from the perspectives of pediatric medical providers and interpreters.
DESIGN/ PARTICIPANTS/ SETTING: We used Group Level Assessment (GLA), a structured qualitative participatory method that allows participants to directly produce and analyze data in an interactive group session. Participants from a single academic children’s hospital generated individual responses to prompts and identified themes and relevant action items. Themes were further consolidated by our research team and verified by stakeholder groups.
RESULTS: Four GLA sessions were conducted including 64 participants: hospital medicine physicians and pediatric residents (56%), inpatient nursing staff (16%), and interpreter services staff (28%). Barriers identified included: (1) difficulties accessing interpreter services; (2) uncertainty in communication with LEP families; (3) unclear and inconsistent expectations and roles of team members; and (4) unmet family engagement expectations. Drivers of effective communication were: (1) utilizing a team-based approach between medical providers and interpreters; (2) understanding the role of cultural context in providing culturally effective care; (3) practicing empathy for patients and families; and (4) using effective family-centered communication strategies.
CONCLUSIONS: Participants identified unique barriers and drivers that impact communication with LEP patients and their families during hospitalization. Future directions include exploring the perspective of LEP families and utilizing team-based and family-centered communication strategies to standardize and improve communication practices.
© 2019 Society of Hospital Medicine
Immigrant children make up the fastest growing segment of the population in the United States.1 While most immigrant children are fluent in English, approximately 40% live with a parent who has limited English proficiency (LEP; ie, speaks English less than “very well”).2,3 In pediatrics, LEP status has been associated with longer hospitalizations,4 higher hospitalization costs,5 increased risk for serious adverse medical events,4,6 and more frequent emergency department reutilization.7 In the inpatient setting, multiple aspects of care present a variety of communication challenges,8 which are amplified by shift work and workflow complexity that result in patients and families interacting with numerous providers over the course of an inpatient stay.
Increasing access to trained professional interpreters when caring for LEP patients improves communication, patient satisfaction, adherence, and mortality.9-12 However, even when access to interpreter services is established, effective use is not guaranteed.13 Up to 57% of pediatricians report relying on family members to communicate with LEP patients and their caregivers;9 23% of pediatric residents categorized LEP encounters as frustrating while 78% perceived care of LEP patients to be “misdirected” (eg, delay in diagnosis or discharge) because of associated language barriers.14
Understanding experiences of frontline inpatient medical providers and interpreters is crucial in identifying challenges and ways to optimize communication for hospitalized LEP patients and families. However, there is a paucity of literature exploring the perspectives of medical providers and interpreters as it relates to communication with hospitalized LEP children and families. In this study, we sought to identify barriers and drivers of effective communication with pediatric patients and families with LEP in the inpatient setting from the perspective of frontline medical providers and interpreters.
METHODS
Study Design
This qualitative study used Group Level Assessment (GLA), a structured participatory methodology that allows diverse groups of stakeholders to generate and evaluate data in interactive sessions.15-18 GLA structure promotes active participation, group problem-solving, and development of actionable plans, distinguishing it from focus groups and in-depth semistructured interviews.15,19 This study received a human subject research exemption by the institutional review board.
Study Setting
Cincinnati Children’s Hospital Medical Center (CCHMC) is a large quaternary care center with ~200 patient encounters each day who require the use of interpreter services. Interpreters (in-person, video, and phone) are utilized during admission, formal family-centered rounds, hospital discharge, and other encounters with physicians, nurses, and other healthcare professionals. In-person interpreters are available in-house for Spanish and Arabic, with 18 additional languages available through regional vendors. Despite available resources, there is no standard way in which medical providers and interpreters work with one another.
