Nursing Practices that Improve Care for Children and Families with Limited English Proficiency Anna Zimmerman, MSW Seattle Children’s Hospital

Background  Children in LEP families often receive medical care without professional interpretation, despite increased risks of medical error, excessive testing and family discontent.  Poor communication is associated with poor care, especially for critically ill children.

Background  United States law and Joint Commission require health care organizations to offer and provide language assistance services at no cost to each patient with LEP. (DSHS 2001, Joint Commission 2010)

What role do nurses play in providing interpretation?  Inpatient nurses communicate with patients and families throughout the day  Nurses are challenged to assess patient and family language need  Nurses must decide when and how to use interpretation resources

Objective This study explored pediatric nurse practices and perceptions of current nursing use of interpretation services.

Methods  13 nurses interviewed from 5 pediatric units  Nurses selected based on availability  Interviewed minutes, audiotaped, transcribed  Open-ended questions explored how nurses care for LEP families Decisionmaking process on providing interpreters Exploring value of communication in patient care  Transcripts coded into distinct units of meaning and categorized

Results: Interpreted communication improves nursing care for LEP patients and families  Families understand care plan and are less stressed  Supports family involvement in decision making  Strengthens nurse-family therapeutic alliance “Non-medical” conversations are opportunity to build relationship with family Every time I use [an interpreter] I feel like parents are happy because they know who I am. I am not just some stranger coming in and messing with the pumps when they are sleeping.

Results: When are families less likely to receive interpretation  “Getting by” for perceived non-medical issues  Use family member or patient as interpreter  Parental refusal  Barriers to using in-person interpretation on weekend/night Dad had limited English skills and mom had no English. I asked Dad if he wanted to use the phone interpreter and he said, just tell me the information and if I feel like I need more explanation I can get on the phone. So, I did that and Dad spoke to the wife to tell her the information.

Results: Consequences of inadequate interpretation  Delays in care  Misunderstandings and cultural barriers  Parental waiting without news  Risk of medical error  Less connection with family members who are not present I definitely receive less contact from LEP families. That may be because they don’t know the numbers to call..[or] that they can use an interpreter to contact us. They might not feel as involved in the care.

Results: Nurse or family decision to use interpretation?  Half of nurses believed that the nurse herself needed an interpreter to provide quality care  Interpretation enabling the nurse to do his/her job  These nurses better able to navigate difficult situations  The other nurses believed that the family should dictate when interpretation is used  This results in more ‘ad hoc’ interpretation and lack of use of interpreters

Results: Phone vs. in-person interpretation  In-Person  Used for rounds, consent, medical protocol, admission/discharge, change in plan of care, teaching/demonstrations, care conferences, emotionally charged conversations  Phone  Used for start of shifts, for basic & quick topics, questions from family, rare languages, when unable to schedule in person

Phone Interpretation  Instantly available  Simple to use  Well liked by those who use regularly  Critical for use on “less important” topics  Nurses concerned about resource utilization and time  Rare languages  When unable to plan ahead Strengths

Emergency DepartmentInpatient Room Examples of phone interpretation

In-Person Interpretation  Captures non-verbal communication  Needed for teaching for care/discharge  Quicker for rounds  Dedicated professional interpreters  Timely Service  Important for admission, discharge, emotional discussions Strengths

Conclusions  Nurses felt interpretation strengthened therapeutic relationship, improved quality of care and reduced risk of medical error  Availability of interpreter services does not guarantee use  Interpretation critical to communication and effective nursing care

Conclusions  Opportunities for improvement  building rapport  avoiding use of non-professional interpretation  telephone for quick communication  Whether to use an interpreter is not just the family choice but is central to core nursing role

Implications for nursing practice  Regular measurement of interpretation being provided to LEP families on each nursing unit  Feedback on interpreter use to nursing units  Promote telephone interpretation as essential tool for timely and frequent communication  Developed toll-free access line for LEP families  Hospital emphasis on medical interpretation as a core service with professional standards

Thanks!