Article

Providers’ Perceptions of Medical Interpreter Services and Limited English Proficiency (LEP) Patients: Understanding the “Bigger Picture”

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Abstract

Patient’s ability to understand and effectively communicate health information facilitates disease prevention, self-management of illness, the adoption of healthy behaviors, and their ability to act on important public health information. However, patients who have limited English proficiency (LEP) are significantly disadvantaged. Previous studies have shown the benefit of medical interpreter services in bridging the health communication gap between patients and providers. This qualitative study, focusing on medical interpreter utilization within obstetrical and neonatal services, provides perspectives from multiple types of providers to further explore the role of medical interpreter services and specific barriers to the use of such services. Five separate focus groups were conducted with postpartum nurses, labor and delivery/triage nurses, obstetrics and gynecology (OBGYN) resident physicians, neonatal intensive-care unit (NICU) nurses, and faculty physicians, nurse practitioners, and midwives. The data show that barriers to the utilization of professional medical interpreters can be categorized by distinct but related institutional- and individual-level factors. Further interpretation of the barriers, however, suggests that providers’ use/non-use of interpreter services is merely one piece of a much “bigger picture” regarding difficulties and challenges in delivering care to a growing culturally diverse patient population, and that these cultural challenges, not just the availability of interpreter services, may affect providers’ ability to deliver effective and efficient care. It is argued that simply adding additional communication-based resources may not be sufficient to impact providers’ attitudes and behaviors or the overarching organizational culture regarding LEP patients.

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... A qualitative study revealed that suboptimal interpreter scheduling and a limited number of available in-person interpreters are barriers to the provision of language services when they would be preferred. [14] Many providers also "expressed dissatisfaction, distrust, and frustration with the telephonic interpretation", further limiting receipt of needed services. [14] When language services are unavailable or when there is a time constraint, providers utilize ad hoc methods to communicate with patients, such as consulting the internet or smartphone translation applications, getting by with gestures, relying on untrained bilingual staff or family members, or relying on the provider's limited foreign language ability. ...
... [14] Many providers also "expressed dissatisfaction, distrust, and frustration with the telephonic interpretation", further limiting receipt of needed services. [14] When language services are unavailable or when there is a time constraint, providers utilize ad hoc methods to communicate with patients, such as consulting the internet or smartphone translation applications, getting by with gestures, relying on untrained bilingual staff or family members, or relying on the provider's limited foreign language ability. [14] These methods are utilized even when providers are aware of the benefit of language services and the associated legal and medical risk. ...
... [14] When language services are unavailable or when there is a time constraint, providers utilize ad hoc methods to communicate with patients, such as consulting the internet or smartphone translation applications, getting by with gestures, relying on untrained bilingual staff or family members, or relying on the provider's limited foreign language ability. [14] These methods are utilized even when providers are aware of the benefit of language services and the associated legal and medical risk. [14] 1.4.2 ...
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... Cultural literacy enhances evidence-based findings that positive patient-provider relationship improves patient health outcomes [7,8,12,[29][30][31]. Although the patient-provider relationship is an intrinsically valued goal in healthcare, when providers encounter an LEP patient, the challenges of language barriers may overshadow this goal [32]. This challenge can hinder building trust. ...
... Awareness of cross-cultural differences in cultural orientation can improve how providers communicate with their LEP patients. Patient-centered communication means engaging with their patient, which can lead to a positive perception of care [26,32]. To be truly patient-centered, the provider cannot remain culturally neutral but rather needs to be more culturally sensitive, which can be done by increasing one's cultural literacy [11]. ...
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We explored how addressing culture may improve patient-provider relationships and reduce health disparities for racial and ethnic individuals with limited English proficiency (LEP). We analyzed qualitative data collected to explore health disparities in preventive cancer screenings for Hmong and Spanish-speaking LEP patients in a large Midwest healthcare system. We interviewed 20 participants (10 from each group) and the audiotaped interviews were transcribed verbatim, then back translated focusing on meaning. Data was analyzed using content analysis. Two themes are: conversation is relational and quality time is valued. Good communication skills involve the amount of conversation, clear explanations, and engaging with the patient. Quality of time meant physical time spent with patient and the task-oriented nature of the encounter. Cultural literacy in healthcare practice helps to understand the whole patient rather than focusing on the symptoms of illness. Patients should not be treated in isolation of their culture. A patient-centered approach to care means physicians should not remain culturally neutral but be more culturally sensitive. We propose steps to reduce disparities by increasing the awareness of cultural literacy for physicians to improve patient-provider relationship.
... Regardless of race, ethnicity, or language proficiency, practicing orthopaedic surgeons should be supported while caring for Spanish-speaking patients; systems that facilitate their communication, maintain workflow, and continue to preserve practice policies should be strengthened. Perceptionbased studies have shown that physicians identify several barriers when caring for Spanish-speaking patients, including a lack of available in-person interpreters, the perception of unreliable telephone interpretation services, a lack of notification that a patient has limited English-language proficiency prior to the encounter, and general time constraints 31 . Opportunities for better support of non-Spanish-speaking orthopaedic surgeons, which will ultimately enhance the care for Spanish-speaking patients, include: ...
Article
Language-concordant care improves patient satisfaction. Given the increase in Spanish-speaking persons requiring orthopaedic care in the United States, it is essential to increase the Spanish-speaking workforce in orthopaedic surgery. We have proposed strategies to improve the proportion of Spanish-speaking orthopaedic surgeons in the U.S. through early exposure to orthopaedic surgery, by creating collaborative advancement and mentorship opportunities, by endorsing Spanish-language immersion opportunities, and by increasing workforce diversity awareness. Furthermore, we have suggested a strategy to better equip non-Spanish-speaking orthopaedic surgeons while caring for Spanish-speaking patients. Together, the suggested strategies offer a variety of approaches that can have a direct, tangible impact on optimizing orthopaedic care while enhancing patient-physician communication in the Spanish language.
... The researcher focuses on in-person interpretation in this study, which occurs face-toface between the interpreter and the patient. As Michalec, et al., (2015) reported, several patients indicated that having an in-person interpreter would put them at ease, allow for the reception/interpretation of emotions expressed through body language, and increase the intimacy of the conversation. However, a medical interpreter's level of ability and expertise is often a constraint on providing an outstanding interpretation session. ...
... According to hospital policy at the field site, patients have the right to request interpreter services at any time during their hospital visit, and also have the right to decline the offered services of a certified staff interpreter in favor of their own representative, such as a bilingual family member. However, as Michalec, Bell, Ehrenthal, Maiden, and Ortiz (2015) explains, even though there have been federally established laws and policies that dictate the use of language services for patients of limited English proficiency, such as Title VI, providers across the board have expressed that there are multiple institutional and practical factors that influence their decision to use or not use an interpreter. ...
Thesis
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This thesis explores the agency (decision making ability) and resource-seeking behaviors of Spanish-speaking patients of limited English proficiency (LEP) when communicating with a biomedical physician through an interpreter. It aims to understand how power dynamics in these mediated encounters may influence patient agency or the exchange of information regarding healthcare resources (e.g., inpatient, outpatient, or community resources). It clarifies how interpreters are brokering access to resources within the U.S. biomedical healthcare system, as well as how patients and providers gauge the effectiveness of interpreter mediation for obtaining knowledge of/access to appropriate resources. My research seeks answers on how the presence of a cultural and linguistic intermediary (an interpreter, potentially of different ethnicity or race as the patient) during interactions between patient and provider changes power dynamics during communication between parties. This thesis explores these queries from the theoretical framework of practice theory. Methods of data collection include participant observation and semi-structured interviews, and I use Foucauldian discourse analysis to scrutinize findings.
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BACKGROUND/OBJECTIVES Patients who use a language other than English (LOE) for health care communication are at increased risk of experiencing adverse events and worse outcomes. The objectives of this research are (1) to understand the lived experience of families who speak LOEs around the hospitalization of their child and (2) to understand the perspectives of patients and families who speak LOEs on opportunities to improve their experiences during hospitalization. METHODS This study is grounded in patient- and family-informed research. We designed a qualitative study involving children hospitalized in the general pediatric inpatient unit at a Canadian children’s hospital. We conducted semistructured individual interviews with children and families with a medical interpreter. We used thematic analysis, and all interviews were coded by 2 reviewers. RESULTS A total 20 families of 16 different languages participated in the interviews. Themes important to understanding their lived experience were the following: (1) communication uncertainty—families experienced inconsistent interpreter use and availability, which affected in-the-moment communication and families’ ability to understand the overall clinical context, leading to increased uncertainty; (2) lack of belonging—despite communicating that they had positive experiences in the hospital, families described a lack of belonging and felt that they were “other” during hospitalization; (3) altered trust—in addition to language, each patient/family’s unique and complex social contexts contribute to developing an altered trust relationship with the health system that impacts their engagement in care processes. Families described opportunities for improvement such as supporting patient-initiated interpretation, increasing workforce diversity, and tailoring concepts such as shared decision making to their realities. CONCLUSIONS Patients and families also revealed that they experience communication uncertainty, altered trust, and a lack of belonging within the hospital setting. Our research builds on the current literature and serves to advance our efforts to address health inequities experienced by this population.
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This paper examines a segment of medical social life that has not been studied extensively: formal presentations of case histories by interns, residents, and fellows. Because they are presented by physicians in training to their status superiors, who are evaluating them, case presentations are exercises in self-presentation which serve as a vehicle for professional socialization. This analysis of the language of case presentation is based on case presentations collected in two intensive care nurseries and an obstetrics and gynecology service. Four features of case presentation are identified: 1) the separation of biological processes from the person (de-personalization); 2) omission of the agent (e.g., use of the passive voice; 3) treating medical technology as the agent; and 4) account markers, such as "states," "reports," and "denies," which emphasize the subjectivity of patients' accounts. The language of case presentation has significant, if unintended, consequences for those who use it. First, some features of case presentation eliminate the element of judgment from medical decisions and mitigate responsibility for medical decision making. Second, some are rhetorical devices which enhance the credibility of the findings that are presented. Third, the language of case presentation minimizes the import of the patient's history and subjective experience. Finally, case histories socialize those who present them to a culture or world view which may contradict the explicit tenets of medical education.
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Language barriers present a major obstacle to minority ethnic communities accessing primary healthcare. Whereas it is recognised that interpreting services are generally inadequate and inappropriate reliance is placed on family members to interpret, little is known about how nurses working in primary care utilise interpreters to overcome language barriers. The present paper reports on a study examining the utilisation of interpreting services by a range of primary care nurses from the perspectives of the nurses, interpreters and minority ethnic communities. Focus groups were undertaken with five separate groups of district nurses, health visitors, practice nurses, community midwives and specialist nurses, three groups of interpreters from different interpreting services, and five groups of participants from the main community languages in the locality where the study was undertaken (i.e. Arabic, Bengali, Cantonese, Somali and Urdu). Focus group discussions were tape-recorded and subsequently transcribed. Data analysis drew upon the principles of 'framework' analysis. The use of interpreters by primary care nurses varied considerably. Nurses who had received training in using interpreters and who had most control over the timing of patient visits were more likely to use interpreting services. Inadequate training of both nurses and interpreters adversely affected the quality of interaction where interpreters were used. Primary care nurses acted as gatekeepers to interpreting services. Whereas interpreting services were generally perceived to be inadequate, many nurses were accepting of the status quo and prepared to rely on family members to interpret rather than champion the need to improve services.
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To determine if professional medical interpreters have a positive impact on clinical care for limited English proficiency (LEP) patients. A systematic literature search, limited to the English language, in PubMed and PsycINFO for publications between 1966 and September 2005, and a search of the Cochrane Library. Any peer-reviewed article which compared at least two language groups, and contained data about professional medical interpreters and addressed communication (errors and comprehension), utilization, clinical outcomes, or satisfaction were included. Of 3,698 references, 28 were found by multiple reviewers to meet inclusion criteria and, of these, 21 assessed professional interpreters separately from ad hoc interpreters. Data were abstracted from each article by two reviewers. Data were collected on the study design, size, comparison groups, analytic technique, interpreter training, and method of determining the participants' need for an interpreter. Each study was evaluated for the effect of interpreter use on four clinical topics that were most likely to either impact or reflect disparities in health and health care. In all four areas examined, use of professional interpreters is associated with improved clinical care more than is use of ad hoc interpreters, and professional interpreters appear to raise the quality of clinical care for LEP patients to approach or equal that for patients without language barriers. Published studies report positive benefits of professional interpreters on communication (errors and comprehension), utilization, clinical outcomes and satisfaction with care.
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This paper explores physician perceptions of the ways professional and family interpreters affect their performance of doctor-communication tasks described in the Calgary-Cambridge Framework. Physicians' (19) encounters with patients (24) accompanied by an interpreter were videotaped. Stimulated recall was used to elicit each of the participants' perceptions of the clinical encounter. We analyzed transcriptions of the physician interviews using Atlas-ti software. Physicians perceived all communication tasks to be more difficult using an interpreter than when one was not needed. Physicians perceived family interpreters to be less skilled translators than professional interpreters. Physicians expected professional interpreters to serve as culture brokers at least some of the time. Although only some family interpreters were also caregivers, physicians assumed that all of them fulfilled caregiver roles. With professional interpreters, physicians follow communication rules they were taught. In contrast, physicians act as though these rules are not relevant with family interpreters who they treat as caregivers. Guidelines to working with an interpreter should include directives on working with both professional and family interpreters, describing the similarities and differences with each type, and modifying the clinical encounter process to correspond to those attributes.