Enhancing Interpreter Use for Patients With Non-English Language Preference in a Pediatric Center for Cancer and Blood Disorders

Abstract

Background

Ineffective interpretation leads to delayed diagnoses and treatment plans and patient dissatisfaction.

Method

A guideline was developed for a center for cancer and blood disorders unit to improve interpretation services for patients and families with non-English language preference (NELP), signage was installed to adequately identify interpretation needs, video remote interpreter (VRI) devices were purchased for the unit, and patients and families were prompted daily to monitor if interpretation services had been used. Adherence to interpreter use was tracked via documentation in the electronic health record.

Results

There was a 59% increase in interpreter use for patients and families with NELP. The National Research Corporation Health Discharge Survey conducted for patients with NELP demonstrated a 6% improvement in questions regarding communication and input in their care while in the hospital.

Discussion

The continual increase in documentation of interpreter use for patients with NELP over a 12-month period alludes to the sustainability of this project. The multipronged approach allowed for patients with NELP to have increased access and contact with interpreters, which translated to improved patient and caregiver perception of communication with their medical team and increased input in their medical care.

Keywords

limited English proficiency oncology pediatrics interpreting devices health equity

Introduction

Non-English language preference (NELP) indicates an individual speaks English less than “very well” and, in 2024, accounted for 8% of the total population in the United States (Gonzalez-Barrera et al., 2024). When translational services are not used in hospitalized pediatric patients who have NELP, increased hospital length of stay (LOS), increased healthcare spending, decreased patient satisfaction scores, and a further perpetuation of healthcare disparities can occur (Choe et al., 2019; Ondusko et al., 2021). These disparities can be attributed to ineffective and non-timely communication with patients and their caregivers when obtaining health histories, assessing a patient's clinical status, answering questions, or obtaining consent (Choe et al., 2019; Ondusko et al., 2021).

Problem Description

It was identified that from May 2020 to May 2021, 17% of patients on a pediatric inpatient hematology and oncology and stem cell transplant unit within a large, urban freestanding children's hospital were categorized as NELP. However, according to the hospital Patient Family Experience (PFE) Committee, from September 2021 to May 2022, interpreters for patients and families who have NELP were only used 22% of the time. This information was gathered via electronic health record (EHR) documentation of interpreter use. When language interpretation services are not used routinely, diagnoses and treatment plans can be delayed, and patient dissatisfaction can occur (Jucket, 2014).

Available Knowledge

When professional interpreters are not used for patients with NELP, there are higher rates of medical errors, decreased adherence to treatment regimens, and often an increased LOS (Feiring & Westdahl, 2020). Patients with NELP understand their diagnosis or daily plan of care less than English-speaking patients due to limitations in interpretation availability (Zamora et al., 2016). Furthermore, patients with NELP and hematology-oncology diagnoses are more likely to misunderstand their disease and treatment because of the complexity and emotional nature of the diagnoses (Granhagen Jungner et al., 2021). Patients with NELP also report they are less comfortable asking their nurses questions while hospitalized or when calling a physician who is on call with urgent questions (Stephen & Zoucha, 2020; Zamora et al., 2016).

Use of interpreters has been found to have variable effects on the number of days the patient is admitted, LOS, and readmission rates (John-Baptiste et al., 2004; Karliner et al., 2017). It is well supported in the literature that LOS and readmission rates in all patients, but especially patients with NELP, are dependent on support systems, cultural influences, acuity of the patient, and preexisting comorbidities, and not specifically dependent on the use of interpreters throughout the admission (Karliner et al., 2010; Taira et al., 2019). At an urban medical center on a general medicine unit, patients with NELP who used qualified interpreters or interpreting devices (i.e., telephonic or video remote interpreters [VRIs]) during their hospital stay had reduced readmission rates and associated increased cost savings related to the decrease in hospital readmission (Karliner et al., 2017).

Communication for patients and families with NELP can be divided into (a) communication between the provider and the patient, (b) communication between the patient and the interpreter, and (c) the patient's communication preference. Despite the presence of dedicated interpreters or interpreting devices, medical providers report inconsistent interpreter use and rely on ad hoc family members to interpret for the patients, which results in a poor quality of communication between providers and patients (Choe et al., 2019). The use of ad hoc family members as interpreters is defined as a family member who has not had formal training to provide medical interpretation. Family members should not be used as medical interpreters, as there is often a concern of objectivity and a lack of formal medical interpretation training (Rimmer, 2020). Medical providers’ avoidance of using qualified interpretation modalities can be attributed to a lack of clinician time to obtain a certified interpreter and distrust in phone or video interpretation services to relay accurate medical information (Granhagen Jungner et al., 2021). The distrust that the medical providers have in phone or video interpretation services was attributed to the concern that what was being told to the interpreter was not accurately translated into the other language (Granhagen Jungner et al., 2021). Furthermore, avoidance of using qualified interpreters can be attributed to patients’ and providers’ perceived cost of interpreter use (Khoong & Fernandez, 2021).

Further barriers to using interpreters in the pediatric inpatient setting include a limited number of interpreting devices and limited knowledge regarding the impact and efficacy of high-quality interpretation (Granhagen Jungner et al., 2021). When an inpatient unit clarified how to obtain a qualified interpreter, increased the number of video or telephonic interpreting devices, and created dedicated storage spaces for the interpreting devices, interpretation was found to occur more consistently (Khoong & Fernandez, 2021; Rajbhandri et al., 2021). Education for staff members was also found to be integral to ensure appropriate use of interpreters for patients and families with NELP. Education on the importance of high-quality interpretation and the use of video and telephonic interpreting devices was found to improve patients’ understanding of their diagnosis and increase the use of interpreting services by medical staff (Lee et al., 2016; Lopez-Bushnell et al., 2020; Rajbhandri et al., 2021).

The overall satisfaction in care that a patient and family feel can positively correlate with patient outcomes and can enhance patient-centered care (Prakash, 2010). When a patient with NELP requires an interpreter, but an interpreter is not used, there are significant downstream effects that can lead to lower patient satisfaction scores (Ondusko et al., 2021). Zamora et al. (2016) found that 32% of Spanish-speaking patients felt that if they spoke English, they would be more satisfied with their care. Findings from a systematic review conducted by Taira et al. (2019) support the notion that patients with NELP have a higher level of satisfaction after video interpreting devices are used, as compared to telephonic interpretation.

The findings from Lopez-Bushnell et al. (2020) support the use of in-person interpreters over other forms, as they note that the majority of NELP patients preferred in-person interpreters over video or telephonic interpreters. In-person interpretation can allow for enhanced communication, as it avoids technological connectivity issues, allows for enhanced patient understanding, and creates a more personal interaction (Locatis et al., 2010).

Specific Aims

The aim of this project was to develop a guideline for patient and family language interpretation for a pediatric inpatient hematology and oncology and stem cell transplant unit within a large children's hospital. The purpose of the guideline was to improve interpretation services for patients and families with NELP, to ensure all patients with NELP will be cared for using a qualified interpreter, to increase staff recognition of when patients require interpretation, and to increase access to qualified interpreters. The Center for Cancer and Blood Disorders (CCBD) unit's goal for interpreter use for patients and families with NELP was to have interpreter use documented 35% of the time.

Rationale

Prior to starting this project, it was noted that there was great variation in how interpreters were obtained and how NELP patients were identified on the CCBD unit. A thorough barriers assessment was needed to understand existing knowledge gaps regarding interpreter use and the various workflows of staff members in obtaining interpreters. The framework Six Sigma was used to guide this project and comprised of five key components: define, measure, analyze, improve, and control (DMAIC). The framework focuses on defining what the underlying problem is, via the conduction of thorough barrier assessments, and addressing the process that needs to be improved via evidence-based practices to reduce variation in performance (Dawson, 2019).

Method

Design and Setting

The project design and implementation were guided using the Standards for Quality Improvement Excellence (SQUIRE) 2.0 guidelines. This quality improvement project took place on a 48-bed inpatient CCBD unit in a large urban freestanding children's hospital. Prior to the project initiation, the hospital Nursing Quality Committee reviewed the project and deemed it quality improvement and therefore did not require institutional review board approval. The project had three phases: pre-implementation, implementation, and postimplementation.

Interventions

A fishbone session with registered nurses (RNs), advanced practice providers (APPs), physicians, and interpreters was conducted to identify barriers regarding interpreter use and associated documentation of interpreters for patients with NELP. The barriers were categorized to create leading drivers that were found to cause low interpretation use on the CCBD unit (Dawson, 2019). The barriers were categorized into interpreting methods, knowledge gap among staff members, identification of patients with NELP, and workflow and processes.

Prior to project initiation, there was access to a limited number of in-person interpreters, two VRIs, and both hospital-based cell phone and dual-handset phone interpreting services. Despite the availability of video and in-person interpreting services, there were a limited number of VRI devices and limited availability of in-person interpreters. Via the initial barriers assessment conducted on the inpatient CCBD unit, further described below, when staff were asked about different modalities of interpretation and personal preferences, staff unanimously preferred to use in-person or VRI devices, as compared to telephonic interpreters. This was attributed to each of those respective methods allowing for more personalized and empathetic interpreting sessions. Prior to the interventions of this project, documentation of interpreter use was completed by the RN in a preexisting EHR flowsheet and was only documented if the RN was using an interpreter.

Before project initiation, patients who were classified as NELP had a banner in the EHR stating, “interpreter needed.” However, it was difficult to recognize and recall the interpretation needs for patients with NELP when not looking in the EHR. There had been a prior initiative to place a temporary magnet outside of the room of the patient with NELP to indicate that an interpreter was required, but this was used inconsistently. In the fishbone session conducted, staff members disclosed that when they did not know an interpreter was needed prior to entering the patient's room, as the interpreter magnets were rarely used, there were delays in providing quality communication to patients and families. The delays were caused by the staff members entering the patient with NELProom, realizing the need for an interpreter, and subsequently needing to leave the room to find an interpreting device. During the fishbone assessment, staff disclosed that the temporary nature of the interpreter magnets allowed for the magnets to be misplaced or thrown away, which ultimately caused them to be difficult to find. To address this concern, permanent retractable sliding tabs were installed near the patient's door entry with a symbol that signifies that the patient and family are NELP and require interpretation (Agency for Healthcare Research and Quality, 2012). The universal symbol for “requires interpretation” was used to create the image for the patient room signage. The tabs were fabricated by an outside vendor and installed. Once installed, these tabs are activated by the bedside RN when the patient is admitted and highlighted during change-of-shift handoff. There are numerous other permanent sliding retractable tabs outside of the patient rooms that staff members engage with daily (i.e., fall risk, oxygen requirements, etc.). The concept of including the interpreter sliding tab is to integrate this notification into a preestablished staff workflow and to ensure that this tab is always available to RNs to activate.

An interprofessional team, including nursing, nursing leadership, medical and APP leadership, and interpreting services, created a guideline for interpreter services (Supplementary Appendix A). As described in the guideline, it is the expectation that qualified interpreters are used for patients with NELP at a minimum of once every 24 hr. This is an expectation set by the hospital’s senior administration. In consensus with the PFE committee, RNs were educated that they should document interpreter use if an interpreter was used by themselves or any other member of the medical team, such as the use of in-person interpretation during interprofessional bedside rounds. This comprehensive guideline was laminated and displayed on the back of the VRI devices and placed at the nurse's stations. Education was created for all staff to review the new guidelines. Education also outlined the frequency for which patients and families with NELP should be updated using an interpreter. The education was in the format of a power point presentation with interactive questions and knowledge checks throughout the education. RNs and certified nursing associates (CNAs) were educated via one-on-one sessions while working on the unit. APPs were educated during a monthly APP meeting, and the medical residents and attending physicians were educated on the new guideline during their weekly conference. After the education was delivered, all staff members completed a posteducation test to verify their understanding of the new processes, including that they knew where to locate the education and CCBD interpretation workflow guideline.

Five additional VRI devices were purchased for the unit, costing approximately $2,300 total. Attached to the VRI devices were instructions on how to access the device, where to store and charge it, and how to document use of the interpreter, and it included a reminder for staff to clean the device when done using it. There were also signs created for two newly dedicated alcoves on the unit for VRI storage so that staff could consistently locate VRI devices.

It was a priority to engage patients and families in this initiative to ensure they understood their access to free interpretation while in the hospital. The project lead, manager of interpreting services, and director of patient and family education services created a prompt via the GetWellNetwork (GWN) for the television in the patient's room stating, “Interpretation is free of cost and is always available to you and your family. Did you get updates on your plan of care using an interpreter?” The language used in the television prompt was written with health literacy strategies for written materials in mind, ensuring the prompt was written in plain language and included clear instructions (Glick et al., 2023). Due to limitations of scope for this portion of the project, Spanish-speaking patients with NELP were identified as the pilot group, with the option to expand to other languages if the prompt proved successful. This prompt, which was translated to Spanish, occurred every day at 4 p.m. for Spanish-speaking patients listed in the EHR as NELP. The prompt allowed the patients and families to choose “yes” or “no,” but completion was not mandatory. The information from the television prompt was then automatically transferred to an EHR flowsheet. The RN was then able to review the patient’s and caregiver's response. Within the flowsheet in the EHR, a reminder was created for nurses that stated, “if the patient has not been updated yet today using an interpreter, please provide an update for your patient using a qualified interpreter and document the occurrence. For more information about interpretation requirements, reference the interpretation guideline.”

To track and trend monthly data regarding interpreter use pre- and postintervention implementation, information was compiled and given to the project lead by an interprofessional patient and family experience (PFE) task force, interpreting services manager, nurse manager, and data analyst. The implementation phase lasted from September 2022 to April 2023. Interpreter use and documentation within the EHR encompassed any form of interpreter used (i.e., VRI, in-person, or telephone). Patients in the emergency department or other inpatient units of the hospital, regardless of diagnosis, were excluded from data collection. The data were compiled by identifying patients who were listed in the EHR as requiring an interpreter and/or if they have a language other than “English” listed as their primary language. These charts were reviewed by the PFE committee who created a data set that was then given to the project lead. The data collected evaluated if there was daily nursing documentation of interpretation use. Documentation once within a 24-hr period regarding a daily plan of care update, regardless of length of session, mode of interpretation, or member of the care team leading the conversation, was deemed adherent to the unit standards. This standard was set by the hospital. Furthermore, adherence in using the “requires interpretation” tab outside of the patient room was collected via weekly audits conducted by the unit's clinical quality coordinator (CQC). The CQC provided real-time feedback to staff if the tab was not activated. Last, the project lead partnered with National Research Corporation (NRC) health representatives to review responses collected on discharge surveys to understand the impact this project had on satisfaction of patients and families with NELP. The unit's NRC Health Discharge Survey results for Spanish-speaking patients with NELP were used to evaluate communication between care team members and the family before project initiation and after project conclusion. To assess the impact of educational efforts for the medical staff, a posteducational survey was also conducted.

Results

All nurses, residents, and APPs were educated regarding the goals of this project and how to navigate the new interpreter needed guideline. Of the nurses (n = 42) who filled out the posteducational survey, 97% of nurses correctly identified who can provide interpretation in a hospital. Ninety-three percent of the nurses knew that patients with NELP require daily updates with an interpreter, 100% of nurses knew that interpretation at the hospital where the project took place is free of charge, and 78% of nurses stated correctly how to request an in-person interpreter.

During the postimplementation months of May 2023 through September 2023, the average percentage of patients with NELP on the CCBD unit increased from 17% to 20%. Use of interpreters for patients and families with NELP increased from an average of 22% to an average of 53%, with a range of 24% in October 2022 to 81% in September 2023. These percentages reflect overall monthly use. In the postimplementation period, interpreter use was sustained between 64% and 81% one year after initiation of the project (Supplementary Appendix B). A data analyst who worked with the PFE committee obtained the raw data monthly from the EHR and compiled it into a simplified chart to display interpretation service use by month (see Supplementary Appendix B). In the postimplementation period of February 2023–September 2023, “interpreter needed” sliding tabs raw data were compiled, which demonstrated that the sliding tabs were used an average of 75% of the time.

After additional VRI devices were obtained, between September 2022 and August 2023, video interpreters were used an average of 30 times a month (Supplementary Appendix C). Phone interpreter use increased from 32 times a month in August 2022 to an average of 38 times a month between September 2022 and August 2023, and in-person interpreters increased from an average of nine encounters in August 2022 to an average of 11.5 encounters between September 2022 and August 2023. The documentation of refusal of interpreters, which was collected via nursing documentation in the EHR, increased from 34 episodes in August 2022 to 74 episodes between September 2022 and August 2023.

There were no baseline data for the GWN television prompt and EHR integration in asking about the daily use of interpreter. From April 2023 to August 2023, the GWN prompt was initiated 92 times for Spanish-speaking patients. Of the 92 prompts, 22 times Spanish-speaking NELP caregivers responded that they were updated using a qualified interpreter, 11 times Spanish-speaking NELP caregivers stated that they were not updated, and 59 times Spanish-speaking NELP caregivers chose to close out of the question prompt without answering (Supplementary Appendix D).

In the NRC Health Discharge Survey results for fiscal year 2022 (FY22), 76.5% of Spanish-speaking families with NELP reported “there was good communication between different doctors and nurses.” During fiscal year 2023 (FY23), which includes this project's postimplementation period, the scores for the same question increased to 83.3%, which is a 6.6% improvement from FY22 and a 15.1% increase above the FY23 Children's Hospital Association (CHA) benchmark. In the NRC Health Discharge Survey question of “did you have enough input or say in your care?” there was a 4.5% improvement between FY22 and FY23, increasing from 78% to 82.5%, respectively. This is a 6.6% increase above the CHA FY23 benchmark.

Discussion

The impact of enhancement of interpreter use for pediatric patients with NELP was assessed by evaluating interpretation documentation, adherence to using the “interpreter needed” sliding tab outside of patient rooms, and the NRC Health Discharge Survey results. The multipronged approach to increasing the use of interpreters for patients with NELP was effective. Although the average interpreter use did not meet the goal of ensuring “all patients with NELP will be cared for using a qualified interpreter,” the marked increase in interpreter use for patients with NELP did exceed the unit goal of 35%. While it is unknown exactly which intervention caused the largest impact on this project, it was likely that the GWN and EHR integration components were the least effective intervention. The GWN pop-up was not mandatory for patients or caregivers to complete. Although 64% of Spanish-speaking NELP caregivers (n = 59) chose not to respond to the survey, it was possible that they saw the important notice about how interpretation use was free of charge, which impacted their decision to request interpretation services later.

Prior to the intervention period, room identification for patients with NELP was inconsistently used and was not monitored. The sliding door tabs installed outside of the patient room were an effective measure to identify patients with NELP prior to entering the patient room. This is evidenced by the sustained use of the sliding door tabs throughout the intervention period. Furthermore, anecdotes from bedside nurses agree that the new, hardwired sliding tabs outside of patient rooms allow for a consistent way for these patients to be identified.

Despite the inconclusive impact of the GWN/EHR integration data, there was a clear increase in the use of VRI devices after additional devices were placed on the unit. At most, VRI devices were used 81 times in a month, which was three times higher than baseline data. It can be acknowledged that this increase in VRI use may also be reflective of the initiative to increase documentation of VRI use. When evaluating the types of interpreter methods used, an interesting data trend of increased “refusal” of interpreters was documented. The education provided to the unit staff for this project included the requirement to document when patients and caregivers refused interpreters, which could explain this increase. It is recommended that in the future, there is a concerted effort to evaluate why patients and families with NELP are refusing interpreters to better understand trends and possible solutions.

The continual increase in documentation of interpreter use for patients with NELP over a 12-month span alludes to the sustainability of this project. For 5 months in the postintervention period, interpretation use was sustained above 60% (Supplementary Appendix B). Last, via the NRC Health Discharge Survey, it was evident that since the onset of this project, patients with NELP increasingly felt that there was good communication between them and their medical team and that they had adequate input in their care.

To ensure the sustainability of the project after the implementation phase concluded, the project incorporated integration and standardization of the conducted interventions into the processes and workflows of the unit. Integration of the project into daily unit practices occurred by having process and outcome metrics visible to all staff in the CCBD in the unit's breakroom; this created consistent methods of communication regarding the project's impact (Scoville, 2017). Also, it was recommended that the unit continue with monthly observations to ensure adherence to the “CCBD interpreter guideline.” After the conclusion of this project, audits of the “interpreter needed” sliding tabs were transitioned to a unit-based committee, which plans to continuously conduct plan-do-study-act (PDSA) cycles to ensure the tabs and guidelines are being used appropriately. Standardization of the project occurred by outlining the processes RNs and licensed individual professionals (LIPs) (i.e., physicians or APPs) should follow if they have a patient who requires interpretation and by creating permanent processes such as the “requires interpretation” tab outside of the patient room (Scoville, 2017).

Limitations

Limitations of this project include that the GWN/EHR integration only populated for Spanish-speaking patients, as the PFE committee wanted to ensure success from a subpopulation of the NELP patients before expanding to the rest of the NELP population. Ultimately, this intervention was not able to be expanded to patients and families who speak other languages. Other limitations include that the patient and caregiver could close out of the GWN/EHR daily prompt without interacting with it, and that the nurse had to manually look in EHR to evaluate the response from the prompt. By not having an automated alert notifying the staff that the patient and caregiver answered “no they have not been updated with an interpreter yet,” there was a chance that the nurse could overlook this information and not provide a timely update to the family. Additionally, new nurses are continually hired on the CCBD unit, and there is no current plan in place to train them on available interpretation services. This training is dependent on their precepted clinical orientation time. To replicate this project in other inpatient pediatric settings, it is suggested that a detailed barriers assessment is conducted with interprofessional staff to understand the barriers that are encountered on the specific unit. Project interventions conducted in this quality improvement project can likely be replicated with success if there is a dedicated interprofessional team to support the initiation, and there is buy-in from the institution to address and support patients and families with NELP.

Conclusion

Based on the findings from this quality improvement project, it is evident that with enhanced access to interpreters, robust staff education, and standardized identification of interpreter needs for patients with NELP outside their room, there is perceived improved communication between patient and caregiver with NELP. During the period after the project was implemented, there was improved patient and caregiver perception of communication with their medical team and an increased ability for them to have input in their medical care.

Supplemental Material

sj-docx-1-jpo-10.1177_27527530251381782 - Supplemental material for Enhancing Interpreter Use for Patients With Non-English Language Preference in a Pediatric Center for Cancer and Blood Disorders

Supplemental material, sj-docx-1-jpo-10.1177_27527530251381782 for Enhancing Interpreter Use for Patients With Non-English Language Preference in a Pediatric Center for Cancer and Blood Disorders by Carolyn Kass and Jeanne Little in Journal of Pediatric Hematology/Oncology Nursing

Footnotes

ORCID iD

Carolyn Kass

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The funding for the VRI devices was provided by the hospital.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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