Inpatient Communication Barriers and Drivers When Caring for Limited English Proficiency Children

Participants from all groups emphasized that a mutual understanding of roles and shared expectations regarding communication and interpretation style, clinical context, and time constraints would establish a foundation for respect between medical providers and interpreters. They reported that a team-based approach to LEP patient and family encounters were crucial to achieving effective communication.

Driver 2: Understanding the Role of Cultural Context in Providing Culturally Effective Care.

Participants across all groups highlighted three different aspects of cultural context that drive effective communication: (1) medical providers’ perception of the family’s culture; (2) LEP families’ knowledge about the culture and healthcare system in the US, and (3) medical providers insight into their own preconceived ideas about LEP families.

Driver 3: Practicing Empathy for Patients and Families

All participants reported that respect for diversity and consideration of the backgrounds and perspectives of LEP patients and families are necessary. Furthermore, both medical providers and interpreters articulated a need to remain patient and mindful when interacting with LEP families despite challenges, especially since, as noted by interpreters, encounters may “take longer, but it’s for a reason.”

Driver 4: Using Effective Family-Centered Communication Strategies

Participants identified the use of effective family-centered communication principles as a driver to optimal communication. Many of the principles identified by medical providers and interpreters are generally applicable to all hospitalized patients and families regardless of English proficiency: optimizing verbal communication (eg, using shorter sentences, pausing to allow for interpretation), optimizing nonverbal communication (eg, setting, position, and body language), and assessment of family understanding and engagement (eg, use of teach back).

Frontline medical providers and interpreters identified barriers and drivers that impact communication with LEP patients and families during hospitalization. To our knowledge, this is the first study that uses a participatory method to explore the perspectives of medical providers and interpreters who care for LEP children and families in the inpatient setting. Despite existing difficulties and concerns regarding language barriers and its impact on quality of care for hospitalized LEP patients and families, participants were enthusiastic about how identified barriers and drivers may inform future improvement efforts. Notable action steps for future improvement discussed by our participants included: increased use and functionality of technology for timely and predictable access to interpreters, deliberate training for providers focused on delivery of culturally-effective care, consistent use of family-centered communication strategies including teach-back, and implementing interdisciplinary expectation setting through “presessions” before encounters with LEP families.

Participants elaborated on several barriers previously described in the literature including time constraints and technical problems.^14,21,22 Such barriers may serve as deterrents to consistent and appropriate use of interpreters in healthcare settings.⁹ A heavy reliance on off-site interpreters (including phone- or video-interpreters) and lack of knowledge regarding resource availability likely amplified frustration for medical providers. Communication with LEP families can be daunting, especially when medical providers do not care for LEP families or work with interpreters on a regular basis.¹⁴ Standardizing the education of medical providers regarding available resources, as well as the logistics, process, and parameters for scheduling interpreters and using technology, was an action step identified by our GLA participants. Targeted education about the logistics of accessing interpreter services and having standardized ways to make technology use easier (ie, one-touch dialing in hospital rooms) has been associated with increased interpreter use and decreased interpreter-related delays in care.²³

Our frontline medical providers expressed added concern about not spending as much time with LEP families. In fact, LEP families in the literature have perceived medical providers to spend less time with their children compared to their English-proficient counterparts.²⁴ Language and cultural barriers, both perceived and real, may limit medical provider rapport with LEP patients and families¹⁴ and likely contribute to medical providers relying on their preconceived assumptions instead.²⁵ Cultural competency education for medical providers, as highlighted by our GLA participants as an action item, can be used to provide more comprehensive and effective care.^26,27

In addition to enhancing cultural humility through education, our participants emphasized the use of family-centered communication strategies as a driver of optimal family engagement and understanding. Actively inviting questions from families and utilizing teach-back, an established evidence-based strategy^28-30 discussed by our participants, can be particularly powerful in assessing family understanding and engagement. While information should be presented in plain language for families in all encounters,³¹ these evidence-based practices are of particular importance when communicating with LEP families. They promote effective communication, empower families to share concerns in a structured manner, and allow medical providers to address matters in real-time with interpreters present.

Finally, our participants highlighted the need for partnerships between providers and interpreter services, noting unclear roles and expectations among interpreters and medical providers as a major barrier. Specifically, physicians noted confusion regarding the scope of an interpreter’s practice. Participants from GLA sessions discussed the importance of a team-based approach and suggested implementing a “presession” prior to encounters with LEP patients and families. Presessions—a concept well accepted among interpreters and recommended by consensus-based practice guidelines—enable medical providers and interpreters to establish shared expectations about scope of practice, communication, interpretation style, time constraints, and medical context prior to patient encounters.^32,33

There are several limitations to our study. First, individuals who chose to participate were likely highly motivated by their clinical experiences with LEP patients and invested in improving communication with LEP families. Second, the study is limited in generalizability, as it was conducted at a single academic institution in a Midwestern city. Despite regional variations in available resources as well as patient and workforce demographics, our findings regarding major themes are in agreement with previously published literature and further add to our understanding of ways to improve communication with this vulnerable population across the care spectrum. Lastly, we were logistically limited in our ability to elicit the perspectives of LEP families due to the participatory nature of GLA; the need for multiple interpreters to simultaneously interact with LEP individuals would have not only hindered active LEP family participation but may have also biased the data generated by patients and families, as the services interpreters provide during their inpatient stay was the focus of our study. Engaging LEP families in their preferred language using participatory methods should be considered for future studies.

In conclusion, frontline providers of medical and language services identified barriers and drivers impacting the effective use of interpreter services when communicating with LEP families during hospitalization. Our enhanced understanding of barriers and drivers, as well as identified actionable interventions, will inform future improvement of communication and interactions with LEP families that contributes to effective and efficient family centered care. A framework for the development and implementation of organizational strategies aimed at improving communication with LEP families must include a thorough assessment of impact, feasibility, stakeholder involvement, and sustainability of specific interventions. While there is no simple formula to improve language services, health systems should establish and adopt language access policies, standardize communication practices, and develop processes to optimize the use of language services in the hospital. Furthermore, engagement with LEP families to better understand their perceptions and experiences with the healthcare system is crucial to improve communication between medical providers and LEP families in the inpatient setting and should be the subject of future studies.

Disclosures

The authors have no conflicts of interest to disclose.

Funding

No external funding was secured for this study. Dr. Joanna Thomson is supported by the Agency for Healthcare Research and Quality (Grant #K08 HS025138). Dr. Raglin Bignall was supported through a Ruth L. Kirschstein National Research Service Award (T32HP10027) when the study was conducted. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding organizations. The funding organizations had no role in the design, preparation, review, or approval of this paper.