The challenge of tetradic relationships in medically interpreted pediatric primary care visits: A descriptive study of communication practices

Medical Team Practices and Interpreter Alterations on Family-Centered Rounds

BACKGROUND

Robust evidence demonstrates inequities in communication during family-centered rounds for families who use a language other than English (LOE) for health care. This study aimed to characterize the type of interpreter alterations occurring on family-centered rounds and identify medical team communication practices associated with alterations.

METHODS

In this observational study of interpreter-supported family-centered rounds, we recorded and transcribed family-centered rounds encounters for Spanish-speaking families. We assessed measures of medical team communication behaviors and interpreter alterations (omissions, additions, and substitutions) using previously described instruments. We used a content analysis approach to apply defined codes to each interpreted segment and to characterize the nature of interpreter alterations. We assessed the association between medical team communication behaviors and interpreter alterations using χ2 tests.

RESULTS

We recorded, transcribed, and coded 529 interpreted segments of 10 family-centered rounds encounters. At least 1 alteration was present in 72% (n = 382/529) of interpreted segments. Omissions were the most common alteration (n = 242/529, 46%) followed by substitutions (n = 177/529, 34%) and additions (n = 71/529, 13%). Interpretation resulted in a potentially negative alteration in 29% (n = 155/529) and a positive alteration in 9% (n = 45/529) of segments. Greater number of sentences in the segment preceding interpretation was associated with an increase in loss of information (P < .001), loss of social support (P = .003), and loss of partnership (P = .020).

CONCLUSIONS

To improve communication with families that use an LOE, medical teams must abide by best practices for using an interpreter such as frequent pausing to prevent loss of both biomedical and psychosocial information.

Adolescent Interview With a Medical Interpreter: A Standardized Patient Encounter for Pediatric Residents

BACKGROUND

Pediatricians can cultivate a more trusting relationship with their non-English speaking patients by emphasizing the importance of upholding patient confidentiality in the presence of an interpreter. We designed a case for pediatric residents to increase comfort when conducting an adolescent interview using a medical interpreter, emphasizing the importance of upholding patient confidentiality, specifically when discussing sensitive health topics.

METHODS

We developed a standardized patient encounter (SPE) for pediatric residents at a large academic institution that focused on exploring sensitive health topics with an adolescent, non-English speaking female patient using an interpreter. A validated survey was administered upon completion of the case, prompting participants to reflect on their comfort and skills with specific activities before and after the case, and was analyzed using paired t-tests.

RESULTS

Eighty-nine residents participated; 66 were interns and 23 were in their second year of residency. The mean scores of all paired survey items significantly increased after the case (p<0.01), indicating perceived personal growth in all educational objective categories. The majority of the participants (97%, N=86) agreed that they built skills in understanding cultural humility and caring for future patients (mean Likert scores: 4.91 and 5.10, respectively).

CONCLUSIONS

Upon completion of the case, residents reported increased comfort and skills using a medical interpreter for non-English speaking patients within the context of patient-centered care, discussing various sensitive health topics, emphasizing the importance of upholding patient confidentiality, and demonstrating skills in adolescent interviewing. Both medical confidentiality and cultural humility education can be integrated into simulation-based medical education to improve the quality of care for diverse patient populations.

Nursing leadership and influence in practice domains at a Veterans Affairs Health Care System

BACKGROUND

Studies in Veteran populations have examined disparities in health service use, care quality, outcomes and increased demands for behavioral health.

PURPOSE

The purpose is to describe the development of nursing leadership roles that influenced practice improvements and demonstrated outcomes related to health disparities in a Veterans Affairs (VA) population over a 12-year period.

METHODS

The Sundean and colleagues' concept analysis of nurse leadership influence was applied to frame the initiative process and impacts.

DISCUSSION

Antecedents and processes that facilitated leadership development included mentorship, disparities expertise, partnerships, consultation, scholarship, dissemination, advocacy, education, and strong coauthor collaboration. Improvements and outcomes included access to services, improved health indicators, tools, workforce, funding, innovations, and nurse investigator studies, consistent with VA priorities and policy related to disparities and equity. Limitations and barriers were addressed.

CONCLUSION

This initiative models' strategies to increase nurse leadership in health equity and care transformation in health systems and community practices.

A stepped-wedge cluster randomized trial designed to improve completion of HPV vaccine series and reduce missed opportunities to vaccinate in rural primary care practices

OBJECTIVES

To test the effectiveness of a comprehensive team-based intervention to improve human papillomavirus (HPV) vaccination completion rates and reduce missed opportunities to vaccinate in rural Oregon.

DESIGN

Stepped-wedge cluster randomized trial.

PARTICIPANTS

Forty family physicians and pediatricians who are members of the Oregon Rural Practice-based Research Network.

INTERVENTION

Tailored to individual practice needs, components will include (1) practice facilitation with clinicians, nurses, front office staff, and others who have patient contact to redesign patient care and communication strategies to optimize HPV vaccine series completion; (2) workflow mapping adapted to practice context to support HPV vaccine delivery; (3) a practice improvement model designed to firmly establish reminder and recall systems and then standing orders; (4) education for patients and parents that underscores HPV vaccination is safe, effective, and an important approach for reducing cancer risk; and (5) partnering with community organizations to plan and implement a social marketing campaign on HPV vaccination.

MAIN OUTCOME MEASURES

Initiation and completion of the HPV vaccine series as well as reduction in rates of missed opportunities to vaccinate derived from Oregon Immunization Program data.

TRIAL REGISTRATION

ClinicalTrials.govPRS, NCT03604393 : .Trial was registered on July 11, 2018. The first participant was enrolled on September 11, 2018.

Informing physician strategies to overcome language barriers in encounters with pediatric patients

OBJECTIVES

To describe physician perceptions of differences in limited English proficient (LEP) pediatric encounters and the behavioral adaptations they make to provide quality care to LEP pediatric patients.

METHODS

We conducted 30min, semi-structured interviews with 6 family physicians and 5 pediatricians in one health system. Audiotapes from each interview were transcribed verbatim then coded using content analysis.

RESULTS

Multiple aspects of the LEP pediatric encounter were perceived by physicians as different from other encounters: trust and relationship between physician and LEP child/child's family, continuity of care, encounter's structure and flow, patient assessment, and communication barriers. Within each of these themes, physicians identified how they adapt their behavior to improve the quality of care provided to LEP children and families.

CONCLUSIONS

Physicians' made both positive and negative adaptations in LEP pediatric encounters that may impact the quality of care provided to these patients.

PRACTICE IMPLICATIONS

By identification of specific positive and negative behavioral adaptations, this study emphasizes intervention targets, such as demonstrating interest in an LEP pediatric patient's family story and individuality and using common niceties in conversations with LEP children.

Informal interpreting in general practice: the migrant patient's voice

OBJECTIVE

To explore the perspective of Turkish-Dutch general practitioner (GP) patients on informal interpreting from an integrated theory base, focusing on interpreters' roles, trust and power.

DESIGN

Semi-structured in depth interviews were conducted with 21 first-generation Turkish-Dutch migrant patients who made use of informal interpreters to communicate with their GPs. An interview guide was designed based on the theoretical framework of interpreter's roles, trust and power, covering questions about interpreters' role, trust in informal/professional interpreters and power division in the medical consultation. The interviews were transcribed verbatim and analyzed according to the constant comparative method.

RESULTS

Besides providing linguistic translation, informal interpreters were expected to perform the roles of advocates and caregivers of the patients. Informal interpreters were trusted more than professional interpreters, mainly for fidelity reasons, that is, because the patients assumed that informal interpreters would act in their best interests. Although informal interpreters were often perceived as the primary interlocutor, the patients did not feel dominated by them, but rather empowered by their presence.

CONCLUSION

Our findings indicate a connection between the role of the advocate, the fidelity dimension of trust and the perceived empowerment of the patients. By linking interpreters' role to trust and power, this study contributes to theory building in the field of informal interpreting, which is needed to design evidence-based interventions to improve health care delivery to patients with insufficient language ability and thus to advance health care delivery to migrant patients, which is currently lagging behind.

Arab-migrant Cancer Survivors' Experiences of Using Health-care Interpreters: A Qualitative Study

Objective:

This paper is drawn from a larger mixed-method study that sought to explore the cancer experiences of Jordanian and Australian Arab cancer survivors and their family caregivers. This paper specifically focuses on the experiences of the Australian cancer survivors and their use of interpreter services to communicate with health-care providers (HCPs).

Methods:

Individual face-to-face interviews were conducted using a semi-structured interview guide. Data were manually thematically analyzed using an inductive approach.

Results:

Three key themes were identified which highlighted the communication issues the Arab-migrant cancer survivors experienced when using health-care interpreters: (1) “My language is weak” – needing someone to help them when communicating with their HCPs; (2) “I had a problem in the dialect” – the need to understand and to be understood by the interpreters; and (3) “I felt all the time that there is something missing” – not being heard by the interpreter. Low confidence in engaging and using the English language meant many cancer survivors were reluctant to seek support from cancer services or to attend workshops conducted in the English language. Despite the presence of professionally trained health-care interpreters in health-care communications, cancer survivors were frustrated when provided with interpreters who did not speak the same dialect, causing linguistic and cultural discord. This created confusion as information was often misinterpreted, resulting in the delivery and receipt of mixed messages.

Conclusions:

Despite the availability of professionally trained health-care interpreters, our findings identified the need for HCPs to ascertain linguistic and cultural congruence when arranging interpreter services.

Portero versus portador: Spanish interpretation of genomic terminology during whole exome sequencing results disclosure

AIM

Describe modifications to technical genomic terminology made by interpreters during disclosure of whole exome sequencing (WES) results.

PATIENTS & METHODS

Using discourse analysis, we identified and categorized interpretations of genomic terminology in 42 disclosure sessions where Spanish-speaking parents received their child's WES results either from a clinician using a medical interpreter, or directly from a bilingual physician.

RESULTS

Overall, 76% of genomic terms were interpreted accordantly, 11% were misinterpreted and 13% were omitted. Misinterpretations made by interpreters and bilingual physicians included using literal and nonmedical terminology to interpret genomic concepts.

CONCLUSION

Modifications to genomic terminology made during interpretation highlight the need to standardize bilingual genomic lexicons. We recommend Spanish terms that can be used to refer to genomic concepts.

Using interpreters in medical consultations: What is said and what is translated-A descriptive analysis using RIAS

OBJECTIVE

To analyse the concordance of original utterances by healthcare providers (HCP) and patients with the corresponding translations by interpreters using the Roter Interaction Analysis System (RIAS).

METHODS

Video recordings of interpreted consultations were transcribed. Transcription was performed by professional interpreters, who first transcribed consultations in both languages, then provided a translation of what was said in the foreign language. Based on the translations, the videos were coded and analysed using RIAS.

RESULTS

Overall, 19 consultations with a total recording time of 865min were analysed. The main finding is the large difference in the number of utterances in the original language compared to the number of utterances in the target language: about one third of the HCPs' and the patients' utterances were not translated. In no instance were omissions explained to HCP or patient.

CONCLUSION

Interpreters in this sample did not always translate what had been said precisely; they omitted utterances by both HCPs and patients.

PRACTICE IMPLICATIONS

All participants of an interpreted consultation must be made aware of potential omissions in the process of translation. Further understanding of the causes and consequences of omissions is needed.

Working with interpreters: The challenges of introducing Option Grid patient decision aids

OBJECTIVE

We aimed to observe how an Option Grid™ decision aid for clinical encounters might be used where an interpreter is present, and to assess the impact of its use on shared decision making.

METHODS

Data were available from three clinical consultations between patient, clinician (a physiotherapist), and interpreter about knee osteoarthritis. Clinicians were trained in the use of an Option Grid decision aid and the tool was used. Consultations were audio-recorded, transcribed, and translated by independent translators into English.

RESULTS

Analysis revealed the difficulties with introducing a written decision aid into an interpreted consultation. The extra discussion needed between the clinician and interpreter around the principles and purpose of shared decision making and instructions regarding the Option Grid decision aid proved challenging and difficult to manage. Discussion of treatment options while using an Option Grid decision aid was predominantly done between clinician and interpreter. The patient appeared to have little involvement in discussion of treatment options.

CONCLUSION

Patients were not active participants within the discussion. Further work needs to be done on how shared decision making can be achieved within interpreted consultations.

PRACTICE IMPLICATIONS

Option Grid decision aids are not being used as intended in interpreted consultations.