BACKGROUND AND OBJECTIVES: Limited-English–proficient (LEP) patients and families are at risk for worse hospital outcomes due to impaired communication. Family-centered rounds (FCR) have become the preferred format for information sharing among providers and families at pediatric institutions. However, there are limited data on FCR among LEP families, particularly regarding interpretation type. We sought to examine the relationships between interpretation type and FCR satisfaction and efficacy among Spanish-speaking families, the fastest growing LEP population in pediatric hospitals.
METHODS: Spanish speakers admitted to general pediatrics units over a period of 16 months were identified on admission. A bilingual research assistant observed FCR and completed an observation tool, including interpreter type. After FCR, the research assistant interviewed families, collecting parent demographics, FCR experience, and interpreter satisfaction. Associations between interpretation type and satisfaction as well as interpretation type and understanding were tested by using χ2 analyses.
RESULTS: We studied 124 families over 16 months. Most respondents were patients’ mothers (84%), born in Mexico (76%), had grade school education (56%), and spoke limited English (96%). Overall, 83 (73%) reported the interpreter services improved their understanding of their child’s medical condition. Interpreter type was significantly associated with family satisfaction with FCR; specifically, an in-person hospital interpreter or video interpreter was associated with complete caregiver satisfaction (P = .005).
CONCLUSIONS: Spanish speakers report higher satisfaction with face-to-face interpreters during FCR, including in-person and video, compared with telephonic interpreters. Video interpretation via iPad during FCR may be a valuable and accessible approach to improve communication in the care of hospitalized children.
The 2001 Institute of Medicine’s report emphasized 6 pillars of quality health care, including health equity between populations,1 especially patients with limited English proficiency (LEP). Spanish speakers represent the fastest growing minority group in US pediatric hospitals2 and face higher risk for poor outcomes due to impaired communication.3–8
For pediatric inpatients, family-centered rounds (FCR) allow families to partner with providers in medical decision-making.9 The American Academy of Pediatrics suggests FCR should be the preferred format for pediatric inpatients,9,10 and they have become standard of care in North America.11 FCRs’ proposed benefits include improved caregiver satisfaction, improved understanding of the care plan, and improved patient-provider communication.10 However, FCRs’ success may be limited by cultural and language barriers,10 including the need for interpretation.
Previous studies have revealed high satisfaction with FCR among medical staff and English-speaking families,12,13 but few have assessed FCR in Spanish-speaking families. FCR with Spanish-speaking families may fundamentally differ from those involving English speakers. Seltz et al14 and Lion et al15 found Spanish-speaking families often did not receive optimal FCR, especially due to information filtering, which was associated with worse family comprehension.
We sought to study satisfaction with FCR among Spanish-speaking families and association with different interpretation types. We hypothesized that interpretation type would be associated with family satisfaction, specifically, that a certified medical interpreter present on FCR would be associated with highest satisfaction.
We conducted an observational study of FCR with Spanish-speaking families. Institutional review board approval from Alfred I. duPont Hospital for Children was granted. We included Spanish-speaking general pediatrics inpatients admitted between July 2013 and November 2014. One bilingual research assistant (RA) identified, via the electronic medical record, patients who indicated that Spanish was their primary language and needed interpretation. Families who spoke languages other than Spanish were excluded. The RA obtained informed consent before FCR, then observed FCR and completed a rounds observation tool (Supplemental Information 1). The information obtained using this tool included interpretation type used, which was at the medical team’s discretion. Factors that may have impacted interpreter type included availability of a certified interpreter (either on the team or in the hospital), bilingual team members, or an iPad. After FCR, the RA returned to collect family data, including demographics, English reading/writing ability, previous experience with FCR, and satisfaction with FCR. Families were studied only once; they were excluded on subsequent days of that admission and on readmission.
Our institution is a 200-bed tertiary care pediatric hospital. Spanish-speaking families represent ∼15% of inpatients. Nursing or registration personnel screen for the need for interpretation services on admission.
Procedures for FCR
There are 4 general pediatrics inpatient teams at our institution; each performs FCR on each patient daily (typically 8–15 patients per team). A team member invites each family to participate. A medical student or junior resident presents the patient’s case. Family members are typically invited to participate as they wish, including correcting the medical team when appropriate and asking questions during or after the presentation. For families who report preferring a language other than English, multiple interpretation types are available (Table 1).
Rounds Observation Tool
We used an FCR observation tool (Supplemental Information 1) adapted from a previous study,16 which served as a pilot test. Data included which team member presented the patient’s case, whether an interpreter was used, and, if so, interpreter type. The tool also collected whether family participation in FCR was encouraged, including the ability to ask questions, and if additional resources were offered. These items were considered affirmative if a team member solicited questions during or after FCR and if a team member offered resources (such as information or support, care coordination, or social work).
Demographic Data and Family Satisfaction With FCR
Approximately 1 to 2 hours after FCR, the RA interviewed the family member present during FCR by using an interview tool (Supplemental Information 2), which included data regarding family demographics and their FCR experience during FCR. Items included were adapted from the Consumer Assessment of Healthcare Providers and Systems.17
We used 2 principal questions to measure satisfaction with interpretation services: (1) “Using any number from 0 to 10, where 0 is the worst interpreter possible and 10 is the best interpreter possible, how would you rate this interpreter?” and (2) “Did the interpreter improve your understanding of your child’s medical condition?” with answer choices “not at all,” “mostly no,” “somewhat,” and “totally” on a 4-point Likert scale.
We used descriptive statistics to (1) characterize features of FCR according to the rounds observation tool, (2) describe patient/family demographics, and (3) describe family satisfaction with the interpretation used during FCR. Caregivers’ scores about interpreter satisfaction were dichotomized between 10 (highest satisfaction) and <10 (Supplemental Information 2, question 3). We compared the percentage with highest satisfaction by each interpretation type using the χ2 test. Responses for improvement in understanding the child’s medical condition were dichotomized between responses reporting total improvement in understanding compared with somewhat, mostly no, or no improvement. We used the χ2 test to compare these 2 categories by interpreter type (Supplemental Information 2, question 4). We also dichotomized caregivers who responded that interpreter use led to “totally understanding” the child’s medical condition versus any other response and used the χ2 test to compare this by interpreter type.
We asked caregivers for comments about their experience with FCR with 3 open-ended questions (Supplemental Information 2, open questions) elicited by the RA and translated into written English. These comments were organized into themes by 2 separate reviewers, and then appraised for consistency by a third reviewer. Any discrepancies in comment classification by the initial reviewers were discussed, and consensus was reached among all 3 reviewers on its underlying theme.
Observation of Rounds
We studied 124 families over 16 months (Table 2). Two families were approached to participate and declined. Of the 114 who used interpretation, the most common modalities were a live certified medical interpreter (n = 29, 25.4%) or a telephone interpreter during FCR (n = 26, 22.8%). An iPad video interpreter was used in 7 patients (6.1%). In 14 patients (12.2%), FCR were completed in English with a telephone interpreter used later. Twenty-two (17.7%) families received interpretation from a certified physician interpreter. We noted anecdotally that video interpretation via iPad or an in-person certified medical interpreter was translated sentence by sentence, whereas a certified doctor often summarized the case in total to the family.
Of the 124 families included, 104 caregivers (84%) identified themselves as patients’ mothers, and 94 (76%) were born in Mexico. The mean caregiver age was 31.7 years. Most respondents (n = 68, 56%) reported grade school-level education; 44 (36%) reported high school education. Slightly more than half (n = 65, 52%) reported speaking some English, whereas 54 (44%) reported speaking no English. The mean patient age was 3.4 years. The most common admission diagnoses were asthma, bronchiolitis, and dehydration.
When asked to rate the interpreter from 0 to 10, 86% (6 of 7 caregivers) rated iPad interpretation as a “10.” Seventy-three percent (16 of 22 caregivers) rated the certified Spanish-speaking physician as a 10, and 62% (18 of 29 caregivers) rated their certified medical interpreter as a 10. The telephonic interpreter used during FCR or afterward was rated a 10 by 38% (10 of 26 caregivers) and 36% (5 of 14 caregivers), respectively. The difference in interpreter rating across all interpreter types was statistically significant (P = .005). Satisfaction with iPad interpretation was statistically significantly higher than satisfaction with telephonic interpretation during (P < .05) or after (P < .05) FCR.
Regarding understanding of the child’s condition, 83 respondents (73%) reported that the interpretation service assisted in his/her understanding of the child’s condition “totally.” Almost all caregivers (n = 107, 91%) reported that the interpreter improved his/her understanding of their child’s medical condition at least “somewhat.” Fewer than half (n = 51, 41%) responded that he/she understood “a lot” about his/her child’s care. Almost all (n = 123, 99%) respondents who experienced FCR felt doctors showed respect to their input. Almost all (n = 115, 93%) caregivers reported feeling comfortable asking questions during FCR. All respondents (n = 124, 100%) felt the medical team showed respect to their culture and beliefs. There was no statistically significant association between any demographic variable and satisfaction with FCR.
Caregivers’ reported understanding of the child’s medical condition after FCR varied significantly by interpretation type (Fig 1, P = .01). All respondents (n = 7) who used video iPad interpretation on FCR reported interpretation completely aided in their understanding of their child’s medical condition. Approximately 90% (27 of 29) of respondents using a certified medical interpreter during FCR felt similarly. Only 58% (15 of 26) and 50% (7 of 14) of respondents who received telephonic interpretation during and after FCR, respectively, rated interpretation as completely improving their understanding of their child’s medical condition.
When prompted with open-ended questions about FCR, caregivers provided a variety of responses with 3 general themes: communication, anxiety, and trust (Table 3). Of the 102 respondents, 45% (n = 46) of comments involved communication. Approximately one-third of comments involving communication (n = 15) expressed a preference for the type of interpretation they had experienced. Six caregivers (6%) expressed appreciation for a Spanish-speaking physician caring for their child. Another 6% (n = 6) mentioned discomfort they felt about communication during FCR generally or the interpretation type used. Five percent (5%) of respondents commented on improved understanding they experienced by using interpretative services.
Twenty caregivers (20%) commented on anxiety about their experience. One-fourth of those (n = 5, 5%) expressed the desire to understand more about their child’s condition. Another 7 caregivers (7%) expressed nervousness about the rounding process, specifically mentioning the large group of people, and another 6 caregivers (6%) expressed concern about their other children while separated from them.
The last theme from the caregivers’ comments about FCR pertained to trust and/or appreciation for the clinical team (35%, n = 36), specifically appreciation for their efforts in communication (4%, n = 4).
Overall, Spanish-speaking families were satisfied with interpretation services used during FCR; however, satisfaction varied by interpreter type. Face-to-face interpretation with a certified medical interpreter or iPad was associated with highest satisfaction. These findings are unsurprising, because trained in-person and video interpreters have been shown to improve understanding of medical conditions for LEP patients.18,19 Our data on high satisfaction with face-to-face interpretation are consistent with the adult literature as well.20,21
Our study is the first, to our knowledge, to assess the use of a tablet computer interpretation system on FCR. This system may be a promising new approach. Potential advantages compared with a telephonic interpreter include the interpreter’s ability to evaluate body language and other nonverbal communication. Families may feel that the interpreter is more invested in the patient’s case if he/she is visible to them. Families may also correlate the use of technology, such as a tablet, with a modern or state-of-the-art facility; this logic may impact how they view the medical care being provided more generally. Privacy concerns that may surface when using a certified medical interpreter may be less worrisome to families using an iPad. Although this study included Spanish interpreters only, iPad interpretation systems offer the capability to use interpreters of many languages, an obvious advantage over certified interpreters who may speak only 1 language.
Additional study should assess whether interpretation type impacts clinical outcomes, such as readmission rates, and health care costs. Future studies should also evaluate iPad use during FCR with families who speak languages other than Spanish.
Our study’s limitations include the relatively small sample size, lack of blinding, and inclusion of de novo survey items not validated in a previous study. Our data are from a single center, although FCR likely share similar characteristics at all hospitals. Because the interpreter type used was at the team’s discretion rather than randomized, bias may have been introduced. Lastly, a single RA was present throughout FCR and may have been perceived by some families as a part of the care team, affecting some answers about satisfaction. Due to the timing in which our institution adapted the iPad interpretation system, we included only a limited number (7) of these patients. However, this system has become widely used by inpatient teams given their availability, ease of use, and ability to interpret multiple languages using a face-to-face format.
Interpreter type may represent an important aspect of FCR for LEP families who prefer face-to-face interpretation via in-person and video interpretation systems. These approaches may improve the equity of health care for hospitalized children.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2017 by the American Academy of Pediatrics