Communication Experiences of Caregivers Using a Language Other Than English on Inpatient Services

This qualitative study was conducted at an urban freestanding children’s hospital with 594 inpatient beds. Our institution has a robust language services program offering on-site (in-person) staff and contractor services, as well as remote services by video or telephone, which are available on all units. Video and telephone interpreter services are provided by nationally recognized vendors focused exclusively on health care systems, employing specialized medical interpreters. The video interpreter service is accessed through an application on an electronic tablet, with some situated on wheeled carts, and offers professional interpreters across 40 languages, usually available on-demand or within minutes of call initiation. The devices are integrated through hospital information services and technology management groups and use the internal digital network of the hospital for reliable, secure, and smooth connections.

This study was determined to be exempt research by our hospital’s institutional review board. Participants were a purposive sample identified by reviewing the general pediatrics daily census for each patient’s documented preferred language in the electronic health record. Eligibility criteria included any caregiver with a listed preferred language of Spanish, Arabic, Brazilian Portuguese, or Mandarin, which represent the 4 most common non-English languages spoken by our patients/families. We excluded families who were admitted through the Global Patient Services program, because this highly resourced program includes built-in supports (eg, nurse coordinator, patient navigator) to facilitate effective communication that is not experienced by most of our patients. Eligible caregivers were approached by a member of the study team who used tablet-based video interpreter services to present the study and obtain verbal consent from interested individuals.

Physician investigators and bilingual members of our Division of Language Services collaborated to construct the interview guide de novo utilizing the following theoretical frameworks for interpersonal communication: communication accommodation theory and social codes theory.²⁸  Prompts were focused on (1) basic demographic information, (2) communication preferences and self-described familiarity with the English language, (3) techniques or methods used by the medical team that lead to effective communication, (4) perceived challenges in communicating with physicians, and (5) suggestions to facilitate improved communication with physicians. The guide was piloted with 1 faculty member, 1 member of the Division of Language Services, and an institutional group of medical educators with experience in qualitative methodology for clarity of concepts and length. Iterative adjustments to the guide were made as necessary.

An English-speaking member of the research team with a master’s degree in medical education and experience conducting qualitative research (K.D.M.) conducted the semistructured interviews, which were facilitated by a tablet-based video interpreting in the participant’s preferred language for medical care and audio recorded. Our team elected to use video interpreting for this study, because it enabled completion of interviews immediately after consent. Additionally, given that the labor shortage associated with the coronavirus disease 2019 pandemic has led to a significant decrease in on-site staff, we aimed to prioritize in-person interpreters for inpatient clinical encounters, as opposed to our research initiative.

Interviews were conducted in patient rooms, occasionally with a second caregiver present. Each participating caregiver was interviewed once and interviews typically lasted 30 to 50 minutes. Field notes were made during and after the interviews. Before each encounter, interpreters were briefed on the study objectives and encouraged to clarify as needed to account for potential words, concepts, or idiomatic expressions without a direct translation to English or cultural nuances that required further explanation. Participants were approached by the interviewer and informed that she was a physician interested in improving communication for families who prefer an LOE and that she was not involved in the medical care of their child. After each interview, the English content of the recording was transcribed and anonymized. English transcripts were not returned to participants given the language discordance, and member checking was not conducted given that families were discharged from the hospital before transcription. Participants received a $10 gift card at completion of the interview.

We used conventional content analysis of the interview transcripts. Given that there is limited existing literature regarding this topic, conventional content analysis enabled inductive category development from analyzing the text data without preconceived categories.^29,30  Coding was completed by 3 members of the study team (K.D.M., K.T.L., D.W.). The codebook was developed using a standard iterative process based on the first 3 interviews.³¹  Coders independently identified emerging domains and themes and intercoder agreement was assessed for every third transcript. During this process, the coding team discussed any discrepancies for individual codes with a low κ score (≤0.5) until consensus was met, with adjustments made to the codebook as needed. The resulting overall κ score was 0.81. NVivo 12 Software was used to facilitate data analysis. Interviews were conducted until thematic saturation was achieved, with no new information emerging.^32–34  Descriptive statistics were used for the demographic data.

Fifteen caregivers were approached; all agreed to participate in the study. Participants represented 7 countries and reported preferred languages of Spanish, Arabic, Brazilian Portuguese, and Mandarin. Time spent living in the United States ranged from 1 month to 25 years, and familiarity with the English language ranged from none to the ability to understand much spoken English. All participants preferred to communicate about health care needs in their primary non-English language (Table 1). Analysis of interview transcripts led to 3 main domains regarding the communication experience: (1) language services provided and the use of interpreter services, (2) overall communication with pediatric inpatient physicians, and (3) suggestions for improvement in physician communication. Domains, themes, and additional quotations are included in Table 2.

Participants emphasized the importance of communicating in their preferred language during medical conversations with physicians. Three themes emerged, including: (1) strong preference for an interpreter as opposed to no interpreter in medical contexts, (2) in-person as preferred interpreter modality, and (3) concern for quality of interpreting despite appropriate use of interpreter services.

All caregivers preferred to use interpreter services when communicating with physicians, stating they were essential to ensure accurate conversations. Despite some participants reporting a limited ability to understand and/or communicate in English, medical conversations were felt to be challenging because they often included unknown terminology or medical jargon, which was much better communicated in their native language. One participant (Spanish-speaking mother) said, “I do understand actually quite a large amount of English, but in regard to medical terminology, I actually like using an interpreter during those times.”

Some participants mentioned relying on English-speaking family members to interpret, which was often by choice, but could ultimately lead to confusion because they typically lack training or qualifications to act as an impartial interpreter. When families asked for interpreter services, their request was always met, though the modality varied on the basis of availability. Participants reported a preference for in-person interpreter services, compared with video or phone modalities. Connection issues leading to truncated or disjointed conversations with physicians using video and phone interpreter services was a frequently cited difficulty. Despite these challenges, caregivers recognized that video and phone interpreting was still better than lack of interpreter services use. Overall, they reported experiencing high-quality interpreting that improved their level of understanding.

Although in most instances the use of interpreter services successfully facilitated communication, some parents shared that interpreters may miss key points, which might skew the conversations and cause confusion. This was recognized mostly by caregivers with some knowledge of the English language, implying that this might go unnoticed by caregivers with complete dependence on the interpreted content. Caregivers also voiced concern that physicians speaking with a fast rate of speech might negatively impact the content of the message delivered by interpreters who might not receive the appropriate time needed for accurate interpreting.

Caregivers generally reported satisfaction regarding communication with their physicians, with early use of interpreter services identified as an extremely important facilitator. Two themes were identified regarding physician communication: (1) successful communication occurs when the physician takes time to provide detailed explanations and allows space for questions, and (2) unsuccessful communication happens when physicians do not use interpreter services or appear frustrated with the lack of language concordance.

Caregivers identified a physician’s willingness to answer all their questions and ensure understanding as a major contributor to successful communication. One participant (Brazilian Portuguese-speaking mother) described doctors as “quite calm” and that they “take time to talk and explain things and clear up any questions I might have.” It was evident when physicians took their time instead of appearing rushed, which was meaningful to families because it demonstrated both patience and kindness. Physicians demonstrating these attributes were cited as the most effective communicators and helped parents feel that their child was receiving care from a compassionate provider. Physicians who failed to inquire about lingering questions or concerns after relaying medical information contributed to confusion about their child’s care.

Although participants had mostly positive comments regarding their communication experiences, they did identify some challenges. Caregivers felt that some physicians were more patient and comfortable than others when it came to communicating with them. Some parents felt that physicians they had previously worked with were angry that they could not understand the medical conversation in English, which was detrimental to establishing a successful therapeutic relationship. Finally, they found it difficult to communicate with physicians who did not use interpreter services in a timely manner and continued to communicate in English. In those instances, caregivers typically left conversations unclear about what was discussed, and the lack of appropriate communication contributed to additional stress.

Participants shared several recommendations for how physicians could improve their communication with families who prefer an LOE, with 3 main themes emerging: (1) speak slowly and use plain language, (2) augment spoken communication with nonverbal communication, and (3) treat families with respect.

Caregivers encouraged physicians to speak more slowly and focus on eliminating the use of medical jargon. Many felt that the use of plain language, along with frequent pauses, helped to facilitate accurate interpreting with the potential for fewer alterations in the content. This also helped families more easily understand the topics of discussion. They also shared that a slower rate of speech was essential in providing them appropriate time to digest the conveyed information related to their child’s care.

Many caregivers identified the use of hand gestures and body language, along with the use of pictures and demonstrations, as significant facilitators to understanding. This was recognized both by caregivers who experienced appropriate use of interpreter services, along with those who interacted with physicians relying on gestures to convey additional meaning while speaking to them in English. One parent recalled a physician pointing to her child’s leg when discussing the medical problem and how this action helped her to better understand the condition by creating an image to accompany the description. Participants appreciated the additional visual cues they gained through gestures and illustrations and recommended that more physicians use these, especially when discussing care related to body parts or medical procedures, to further illustrate concepts. Caregivers also placed importance on other nonverbal cues, including smiling and the use of a positive tone of voice, which conveys a physician’s level of comfort. These nonverbal communication strategies demonstrated care for their child and helped build trust.

Finally, interviewees also expressed appreciation for instances when the physician communicated care for the caregiver, such as inquiring about their needs when they might not know how to ask for something or what to ask for. Importantly, caregivers also recognized when physicians were impatient during the encounter and reported a negative impact on the development of a therapeutic relationship. Caregivers experience frustration when they are unable to comprehend what is being explained to them and emphasized that taking time to understand their needs demonstrates respect, builds trust, and ensures an effective communication experience with their inpatient physicians.

This study sheds new light on the perspectives of caregivers who prefer using an LOE for health care communication, representing multiple languages on a general pediatrics inpatient service, including facilitators of and barriers to successful communication with their physicians. Though health care providers interact with patients and families who prefer an LOE daily, these individuals continue to experience challenges communicating effectively with physicians, and little is known about the experience of families with preferred languages other than Spanish in the general inpatient setting.

In the interviews, we found that the use of interpreter services was considered essential for clear communication between caregivers and their physicians. These caregivers also indicated a preference for in-person interpreters when available, which is concordant with previous studies.^26,35  Despite recognition of the importance of interpreters in facilitating conversations with families who prefer an LOE, these individuals are inconsistently identified by hospitals, and underuse of interpreter services is consistently documented.^10,36–38  Accurate and timely identification of the need for interpreter services and providing interpreter services for every patient encounter should be prioritized by the medical team.

The caregivers we interviewed reported overall satisfaction with their interpreted conversations; however, a few caregivers with some knowledge of the English language voiced concerns for alterations in the interpreted content of conversations. They acknowledged concern, especially when physicians used medical jargon or failed to pause and allow interpreters to catch up. This has been previously shown in the literature, with documented alterations in interpreted renditions encompassing “additions, omissions, substitutions, editorializations, answering for the patient/clinician, confessions, and patient advocacy”.³⁹  These adjustments in content occur more frequently with use of ad hoc interpreters; however, clinically significant errors in interpreting have also been committed by medical interpreters.^39–42  To reduce this risk, caregivers suggested that physicians focus on using plain language, avoiding use of medical jargon or providing clarification when necessary, and pausing more frequently to facilitate interpreting. These recommendations from caregivers align with previously published guidelines on best practices for use of interpreter services.⁴³ 

In discussing communication strategies used by effective physicians, many caregivers commented on the use of gestures, body language, and drawings as significant facilitators. For some, having a visual image of what was being discussed helped ascribe additional meaning to the content being verbally discussed. This is supported by decades of research showing that both speech and gestures are 2 essential aspects of the communication experience.⁴⁴  Although there is a paucity of literature assessing the use of gestures and body language, specifically with individuals who prefer an LOE, 1 study did show that 70% of gestures in conversations between physicians and patients contained novel information not gleaned from the speaker’s words.⁴⁵  This illustrates the importance of gestures themselves in conveying additional meaning. Moreover, these authors noted that when interpreters failed to mirror the speaker’s body-oriented gesture, there was an alteration to the overall meaning of the utterance. In contrast, interpreters who repeated the gestures along with the speech successfully maintained the overall meaning.⁴⁵  This study, along with the perspectives of the caregivers in our study, helps shed light on the importance of gestures and body language during communication, especially between language-discordant physicians and families. As such, physicians should prioritize the use of in-person or video interpreter services to fully represent an accurate conversation.

It is also important to note that the meaning of gestures can vary drastically among different cultures. This can be particularly challenging with “back-channeling,” which describes how a recipient signals attention to a conversation.⁴⁶  One example is head nodding, which signals affirmation of understanding in many cultures, but in others, merely signals attention to the conversation. Given this, physicians might easily overlook confusion of a nodding patient or caregiver who might be paying close attention to the conversation but not actually understanding the content.^47,48  In these situations, careful consideration of facial expressions and body language, along with cultural competency and knowledge of the main populations one serves, are essential.

Finally, many caregivers identified simple actions such as smiling, speaking with a friendly tone, and conveying concern as components of successful communication, which have been noted in other studies.⁴⁹  Although this may seem obvious, providers might be unaware of the importance of these nonverbal expressions for families who prefer an LOE. It is also crucial to note that impatience is readily recognized by caregivers and only exacerbates the existing discomfort and stress associated with a child’s hospitalization. Physicians should allow ample time for questions and ensure caregiver understanding before concluding a conversation, which our participants identified as the gold standard for preventing lingering doubt or confusion.

Our study is not without limitations. First, the interviews were conducted by an English-speaking interviewer using interpreter services and only the English content of the discussion as rendered by the interpreters was transcribed and analyzed. As such, it is possible that the data analyzed contains undetected alterations in content or meaning. Second, it is possible that the use of video interpreting to conduct the interviews prevented some caregivers from sharing concerns related to the interpreting itself. Third, this study was conducted at a large, freestanding children’s hospital where on-demand video interpreting is readily available. Future studies should assess the experience of families who are admitted in settings where interpreter services are less prevalent. Fourth, by design, we recruited a sample of caregivers that was linguistically representative of the patients we serve. This meant that our sample included fewer interviews for some of the less commonly spoken languages, making it difficult to identify potential thematic differences between specific languages. Fifth, given that there may be cultural nuances that predicate preferences in communication strategies, it is possible our cohort only partially captured these nuances, limiting generalizability. Lastly, our study focused solely on the perspectives of caregivers when communicating with their physicians. Future studies should evaluate the communication experiences with other members of the interdisciplinary health care team.

Overall, the caregivers we interviewed reported satisfaction with the communication with their inpatient pediatricians. Commonly cited challenges, such as delayed use of interpreter services and concern for quality of interpreting, were noted by our participants. Greater emphasis on the use of gestures and body language may enhance conversations with families who prefer health care communication in an LOE. Additionally, adhering to known best practices for using interpreter services, along with practicing patience and allowing sufficient time for questions, are vital for communicating effectively with this important population. Many physicians are proficient in the science of medicine; now is the time to enhance their skills in the art of communication.

We thank the Division of Language Services at Children’s Hospital of Philadelphia for their partnership critical to facilitating interview interpretation.