How would the nurse complete the discharge teaching of a patient with limited English proficiency?

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Research Articles| October 01 2019

Seethalakshmi H. Davis, BA;

Seethalakshmi H. Davis, BA

aSwarthmore College, Swarthmore, Pennsylvania;

bPolicyLab, Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania;

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Julia Rosenberg, MD;

cDepartment of Pediatrics, Yale New Haven Children’s Hospital, New Haven, Connecticut;

dNational Clinician Scholars Program, Yale University, New Haven, Connecticut;

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Jenny Nguyen, BS;

eLewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania;

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Manuel Jimenez, MD, MS, FAAP;

Manuel Jimenez, MD, MS, FAAP

fDepartment of Pediatrics, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey;

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K. Casey Lion, MD, MPH;

gCenter for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington;

hDepartment of Pediatrics, University of Washington School of Medicine, University of Washington, Seattle, Washington; and

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Gabriela Jenicek, MA, CDM;

Gabriela Jenicek, MA, CDM

bPolicyLab, Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania;

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Harry Dallmann, MA;

fDepartment of Pediatrics, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey;

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Katherine Yun, MD, MHS

bPolicyLab, Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania;

iDepartment of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

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POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Hosp Pediatr (2019) 9 (10): 779–787.

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Many pediatric health care disparities in the United States can be traced in part to language barriers.1–3  Access to language services influences quality of care4–7  and readmission rates.8  As the proportion of US children with a parent or caregiver with limited English proficiency (LEP) rises to over 15%,9  it becomes more urgent to direct attention toward language services in pediatric health care settings. There is robust literature on the effective provision of spoken language services for patients while they are in the hospital, through in-person, phone, or video interpreters.10–12  However, little is known about the provision of written language services for patients with LEP, for example, translation.

Clear written communication is particularly important when children are leaving the hospital.13  In a recent systematic literature review, researchers focused on parental management of pediatric inpatient and emergency department discharge instructions and found that common postdischarge errors include not picking up prescriptions, not adhering to medication regimens, liquid medication dosing errors, and missing follow-up appointments.14  Although research on discharge instructions for LEP families is limited, there is evidence that they are more vulnerable to postdischarge errors than English-proficient families.14–16  For example, low-income Spanish-speaking parents are more likely to make liquid medication dosing errors than non-LEP peers,17,18  and LEP individuals are more likely to miss follow-up appointments.19,20  Interventions that have been shown to reduce postdischarge errors for LEP and non-LEP families include provider and/or caregiver demonstrations (eg, “show back”), use of video or pictograms, and pairing verbal instructions with standardized written instructions in the families’ preferred languages.14,21 

Existing federal policy supports the translation of discharge instructions. Hospitals funded by the Department of Health and Human Services are required to take “reasonable steps to provide meaningful access to their programs and activities by LEP persons.”22  This includes translations of “vital documents,” meaning documents vital to a specific program or service and without which an LEP person might suffer adverse consequences.23  Nonetheless, nearly half of hospitals do not translate discharge instructions.24–26 

Given these findings, it is critical to understand both why institutions are not providing translated discharge instructions and how institutions providing translations are able to do so. In this study, we use mixed methods to explore challenges and opportunities related to the translation of written discharge instructions for patients leaving children’s hospital inpatient units. In the project, we focused on the inpatient setting because challenges are believed to be different in ambulatory settings with higher and more rapid patient turnover.

Methods

Participants and Recruitment

From February 2017 through August 2017, we contacted the 200 Children’s Hospital Association (CHA) acute care member hospitals (Supplemental Information) to obtain e-mail addresses for language services directors. Consistent with previous research on hospital language access resources and policies, we believed language services directors to be the individuals most familiar with translation resources and practices.24,25,27  We obtained e-mail addresses for 68 individuals who were e-mailed an online survey with up to 2 reminders. The remaining 132 institutions did not have a designated language services contact person or declined to provide contact information. Study data were collected by using Research Electronic Data Capture.28 

Survey Instrument and Data Collection

Respondents (n = 31) completed a deidentified online survey with 25 questions regarding translation services for pediatric inpatients, including a request for copies of extant translation policies. We considered policies and practices related to translation overall and for discharge instructions, more specifically, given that discharge instructions are a special subset of translatable documents and the overarching policies and barriers apply. Open- and closed-ended questions were focused on both the institution’s overall organization of language services and, more specifically, on the translation of inpatient discharge instructions into languages other than English (Supplemental Information). The survey was developed by the project team, who adapted questions from previous surveys and piloted the instrument with language services professionals.24,27,29 

Additional Data

In November 2017, we conducted an online environmental scan of the 200 acute CHA hospital language services landing pages to find publicly available interpretation and translation policies. Only dated, downloadable files were included in an effort to identify the hospitals’ standard, current policies (n = 22, 7 of which were obtained through the survey).

Additionally, we documented CHA member information (hospital size and health system membership), county-level census data (2015 American Community Survey, 5-year estimates), and metro-level census data (2014 American Community Survey, 2-year estimates) for all hospitals (n = 44) for which we had survey responses or for which an interpretation or translation policy was obtained via environmental scan (Fig 1).9,30  These data were collected to contextualize our sample and to better understand the communities that the respondent institutions serve.

FIGURE 1

Data collection. a 15 from environmental scan, 7 from survey.

FIGURE 1

Data collection. a 15 from environmental scan, 7 from survey.

Close modal

Data Analysis

Survey and census data were examined by using descriptive statistics. Open-ended survey responses and translation policies were coded and analyzed by the project team using inductive content analysis.31,32  The project team independently examined open-ended responses for themes and then discussed themes together. Three members of the project team read the interpretation and translation policies independently and developed a coding scheme. One team member coded each policy, and 2 additional members reviewed the coding. Disagreements were resolved by consensus.

This project was determined not to be human subjects research by the Children’s Hospital of Philadelphia Institutional Review Board.

Results

Survey

Respondent and hospital characteristics are described in Table 1. All but one respondent (97%) reported that their hospital has a mechanism to ensure that information about a patient’s preferred language is available to hospital staff throughout the continuum of care (eg, a flag in the electronic medical record). The majority of respondents (81%) said that their hospital has a written policy pertaining to translation. Others reported having an established procedure but not a written policy (16%). All respondents reported that their institution translates handouts pertaining to patient rights, nearly all reported translating consent documents (97%), and three-quarters (74%) reported translating hospital discharge instructions (Table 2).

TABLE 1

Characteristics of Surveyed Hospitals and the Surrounding Regions (N = 31)

a

The following states are included in the US census regions and divisions: New England (ME, VT, NH, MA, CT, RI), Middle Atlantic (NY, NJ, PA), South Atlantic (WV, MD, DE, VA, NC, SC, GA, FL), East North Central (WI, IL, IN, OH, MI), West North Central (ND, SD, NE, KS, MN, IA, MO), East South Central (KY, TN, MS, AL), West South Central (OK, AR, LA, TX), Mountain (MT, ID, WY, NV, UT, CO, AZ, NM), and Pacific (WA, OR, CA).

b

2011–2015 American Community Survey 5-y estimates.

e

Defined as membership in the Council of Teaching Hospitals and Health Systems.

f

For example, patient door signage.

TABLE 2

Translation Services in Surveyed Hospitals (N = 31)

When asked about clinicians’ approaches for translating hospital discharge instructions, respondents reported that pretranslated materials (87%), professional interpreters (84%), and professional translators (71%) are all used “sometimes” or “frequently” (Table 3). When asked about “adequate training to translate for patients,” respondents described translation-specific qualifications, including American Translators’ Association or university certifications. Some respondents also noted that their institutions permit professional interpreters to translate simple discharge instructions, for example, “For most simple discharge instructions, staff interpreters who have been tested on their ability to read and write both English and the target language coupled with their medical knowledge are able to do a good job.”

TABLE 3

Providing Translated Hospital Discharge Instructions: Strategies and Barriers (N = 31)

a

Staff interpreter: employed by the hospital, assists with verbal communication; staff translator: employed by the hospital, assists with written communication; contracted interpreter or translator: employed by an agency, used by the hospital as needed.

b

Interpreter involvement in the translation process may refer to written translation and/or sight translation.

Only 2 institutions reported that providers “sometimes” or “frequently” use medical translation software to translate hospital discharge instructions (Table 3). No institutions reported making audio recordings of hospital discharge instructions for LEP patients and families.

When asked “What obstacles does your children’s hospital face in providing discharge translation services in the inpatient setting?” the most commonly cited barrier was “operational complexity” (69%; Table 3). However, when asked to name the “greatest” obstacle, an equal number of respondents selected “operational complexity,” “too few translation services staff,” and “funding” (Table 3). When asked to describe their greatest challenge in more detail, respondents described “operational complexity” as a problem with timing (Table 4): “Instructions aren’t finalized until the last minute, and we do not want to delay discharge for hours while we wait for them to be professionally translated.” Respondents who selected “too few translation services staff” reported funding cuts leading to staff cuts as well as reliance on interpreters as translators rather than having dedicated translators. Respondents who selected “funding” described diverse challenges, including insufficient funding to hire needed staff and high costs of providing translation in a wide range of languages and translating long English-language documents.

TABLE 4

Selected Quotes Regarding Obstacles and Strategies in Providing Inpatient Discharge Translation Services

ASL, American Sign Language.

When asked “To what extent do you feel that inpatient clinical staff understand how to access services to translate or audio record inpatient discharge instructions?” responses ranged from “very little awareness” to “Very well. It is ingrained in hospital culture and education.” One respondent who reported high awareness specifically noted that the translation process had been built into their electronic health record (EHR). Some respondents noted that awareness varied by clinical department or unit. Other challenges included high clinical staff turnover, use of Google Translate rather than the institution’s official translation process, and difficulty promoting understanding of the translation process for less-common languages. As one respondent wrote, “They are aware of our process for Spanish translation. I find myself having to remind staff to also access our process for non-Spanish translation discharge needs.”

Most, although not all, respondents described 1 or more strategies that they felt had been successful in providing translation services at the time of hospital discharge (Table 4). Most strategies involved streamlining processes for translating standardized documents. Some respondents cited progress in developing libraries of translated standardized documents (eg, care instructions), and some institutions maintain these documents in a library disseminated via institutional intranet. Other respondents described incorporating translated standardized templates into the EHR. Often, however, translated standardized documents are only available in Spanish or other common languages.

Other strategies included involving interpreters in translation and/or sight translation (defined as in-the-moment verbal communication of a written document in another language33 ), mailing translated personalized instructions to the patient’s home, using (unspecified) technology to allow language services team members to translate documents across the hospital network rather than only within a single hospital, and using unspecified software for machine translation “maintained” by a staff translator using an unspecified quality assurance process. A few respondents reported establishing target time frames for translating discharge instructions, and these ranged from 30 minutes to 24 hours. Many respondents noted that these protocols are only used for the most common local non-English language, generally Spanish.

Translation Policies

We collected policies from 22 different institutions, 7 of which also completed the survey. Most policies included guidance on both interpretation and translation, and among these documents, only 9% of text in the policies focused on translation. Only 1 policy focused exclusively on translation. We identified several themes.

Vital Documents

Most institutions prioritized the translation of “vital documents,” the definition of which varied between institutions. One policy defined a vital document as “any document that would be provided to an English-proficient patient and is necessary for the patient’s health and well-being.” Guiding questions were then suggested for clinical staff to determine if something was a “vital document,” including, “What is the consequence to the LEP person if the information is not provided accurately or in a timely manner?” Other organizations listed types of vital documents, most commonly, consent forms and advance directives, in lieu of a definition.

Sight Translation

Institutional policies that sanctioned sight translation (verbal communication of a written document in another language) generally noted that having a translated written document is preferred when feasible. Some also noted that sight translations should be limited to short texts that cannot be translated because of “practical or time considerations,” explaining that interpreters should not be asked to translate longer or more-complex documents. One institution also required interpreters engaging in sight translation have “active interaction with the [health care] provider” but did not define the nature of that interaction. Another institution specifically forbade sight translation altogether, instead asking that a health care provider “explain the document in layman terms” with the assistance of the interpreter if translation is not feasible.

Interpreters as Translators

As noted above, some institutional protocols allowed interpreters (who specialize in facilitating verbal communication between 2 individuals who do not speak the same language) to serve as translators or sight translators of written materials, although interpreters and translators generally have different training and certification. Many constraints for sight translation also applied for interpreters providing written translations. Several institutions permitted interpreters to prepare written translations of only short, individualized documents and prohibited interpreters from translating more-complex materials. An example of an appropriate document at one institution included individualized discharge instructions that are “handwritten,” for example, instructions for medication administration. One institution noted that only certain interpreters, presumably with a certain level of training or language experience, can translate documents, but other institutions did not specify whether additional training was required.

Translated Document Libraries

Almost every institutional policy that mentioned translation services described maintaining a library of translated, standardized documents that could be used multiple times. Examples included patient education materials, legal documents (eg, consent forms), “routine hospital documents,” and “vital documents.” One hospital described a hospital brochure with maps and hospital information as part of this standardized translated document collection with the rationale that the brochure facilitated equitable access to care. Although many hospital policies noted that document libraries or other centralized collections were available, several also noted that these materials were only available in a few languages, usually the most commonly spoken languages locally.

Machine Translation

Every policy that mentioned machine translation or translation software (n = 5 out of 22) forbade its use alone. Typically, these policies explained that such translation mechanisms were “inaccurate,” “unreliable,” and “unsafe.”

Discussion

The children’s hospitals included in this study experience many shared organizational and operational obstacles to translating inpatient discharge instructions. These include mismatched time frames for translation and patient discharge, staff and funding shortages, and difficulty ensuring clinical staff followed language services policies, especially for languages other than Spanish. Our findings are consistent with previous research in which it was shown that translation is underused,24,34,35  and we add to this literature by elucidating the specific reasons for underuse.

Among the hospitals included in this study, approaches to overcoming challenges to translating discharge instructions included developing libraries of translated standardized documents and incorporating translated, standardized templates into the EHR. Although these approaches may improve access to standardized instructions for a few languages, they do not allow for personalization and may not benefit individuals who speak less-common non-English languages. Notably, LEP individuals in the US speak over 200 different languages.36 

We identified variation and even conflicting guidance across institutions (eg, regarding the definition of vital documents or the use of interpreters for document translation), indicating that health systems have not yet reached a consensus regarding preferred translation practices. This may be explained in part by the flexibility, or ambiguity, of current federal regulations. For example, Section 1557 of the Affordable Care Act requires Health and Human Services–funded providers to use “qualified translators.”37  The final rule defining “qualified translator” acknowledges that interpreters may not necessarily have the requisite skills, but it does not bar interpreters with a specified skill set from serving as translators. Thus, institutions are left to decide how to operationalize the definition of qualified translator, which can be a challenge in the face of limited professional credentialing options and high demand for both interpreters and translators. Similarly, federally funded health systems are required to translate “vital documents” necessary to facilitate “meaningful access” to programs and services, but this definition of “vital document” allows for great variation across health systems, and the focus is often on legal documents. Given the myriad of barriers to translating discharge instructions, perhaps explicitly incorporating discharge instructions into hospitals’ definitions of a “vital document” could facilitate better translation of these critical and consequential materials.

In limited previous research, authors describe either innovative or practical strategies for providing translated discharge instructions in a timely manner. Given the variability in interpretation of the regulations and the lack of formal evaluation of the various approaches described in this article, it seems premature to advocate for any particular approach. However, creative strategies are being developed, and rigorous evaluation of them is needed. For example, a previous national learning collaborative targeted at interpreter services improved such services on at least 1 measure at every participating hospital; a similar program for translation may facilitate collaboration across institutions and improvement in translation services.26  Innovations in other sectors like the public health arena may inform how health systems approach translating discharge instructions. For example, a network of health departments piloted a 2-step process, beginning with high-quality machine translation of health promotion materials (eg, HIV testing information and vaccination clinic announcements) followed by human translator review.34,38  Similar carefully studied innovation is needed in the clinical realm.

This study had several limitations. First, the majority of CHA institutions did not have contact information available for a language services director. Second, among institutions with available contact information, our survey response rate was low (46%). Although this is typical of modern Internet-based surveys, it is possible that our sample is biased toward institutions with greater institutional resources directed toward language services or respondents with greater interest in language services. Third, language services directors served as representatives for institutions. Although language services directors are key informants for questions relating to language services policies, resources, and challenges, data regarding clinician use of different translation strategies are subjective and should be interpreted with caution. Fourth, our sample was limited to a subset of CHA hospitals. CHA hospitals tend to be well resourced and may be larger than other children’s hospitals, so these findings may not generalize to other children’s hospitals or pediatric units within community or nonchildren’s hospitals.

Conclusions

Providing translated discharge instructions for patients and families with LEP remains challenging, and institutions face similar organizational and operational barriers. Several hospitals reported strategies to address these barriers. Some of these approaches, such as the use of translated document libraries and templates, provide a critical foundation for meaningful written communication with LEP families but may not provide equivalent access, especially for families who do not speak a common non-English language. Institutions should also recognize that these approaches are inherently limited in their ability to provide tailored instructions. In addition, there is not yet agreement regarding the appropriateness of different strategies. Beyond continued characterization of the problem, we urgently need innovative interventions to be developed and tested. Active innovation, collaboration across institutions, and rigorous evaluation of candidate strategies should be considered to address the persistent challenges posed by professional translation in the clinical setting.

Acknowledgement

We thank Clara Warden for preparing survey data for analysis, Patty Hencz and Juan Kraus for reviewing survey drafts, and Priscilla Ortiz, Angela Frentress, and Isabel Pachiarotti for reviewing survey drafts and editing the manuscript for clarity and accuracy. We sincerely thank the project participants for sharing their time and expertise.

Ms Davis developed the survey instrument, contacted participant institutions, conducted the online environmental scan, performed the analyses, and drafted and revised the manuscript; Dr Rosenberg piloted the survey instrument, contacted participant institutions, conducted the online environmental scan, and reviewed and revised the manuscript; Ms Nguyen contacted participant institutions, conducted the online environmental scan, and reviewed and revised the manuscript; Drs Jimenez and Yun conceptualized and designed the study, piloted the survey instrument, performed the analyses, and reviewed and revised the manuscript; Dr Lion provided critical input on study design and analyses, piloted the survey instrument, and reviewed and revised the manuscript; Ms Jenicek and Mr Dallmann piloted the survey instrument, reviewed preliminary analyses, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.

FUNDING: Ms Davis’ time was supported by the William L. Huganir Summer Research Stipend on Population Issues at Swarthmore College. Dr Jimenez is supported by the Robert Wood Johnson Foundation through the Harold Amos Medical Faculty Development Program (grant 73308). Dr Lion’s time was supported by National Institute of Child Health and Human Development grant K23 HD078507 (principal investigator, Dr Lion). Dr Yun’s time was supported by National Institute of Child Health and Human Development grant K23 HD082312 (principal investigator, Dr Yun). Funded by the National Institutes of Health (NIH).

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Copyright © 2019 by the American Academy of Pediatrics

2019

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